Basic Information
| Provider Information | |||||||||
| NPI: | 1720041833 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVETT | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2080 | ||||||||
| Address2: | |||||||||
| City: | KILMARNOCK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224822080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8044353508 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1906 BELLEVIEW AVE SE | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240141838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409817000 | ||||||||
| FaxNumber: | 5409856930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 05/02/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 0101047166 | VA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 010046246 | 05 | VA | MEDICAID | 010046271 | 05 | VA | MEDICAID | 010420903 | 05 | VA | MEDICAID | 184296 | 01 | VA | BLUE SHIELD | OTHER |