Provider Demographics
NPI:1003072604
Name:EVANSON, J.RICHARD LEE (DO)
Entity Type:Individual
Prefix:DR
First Name:J.RICHARD
Middle Name:LEE
Last Name:EVANSON
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:300 W HOSPITAL ROAD, ROOM 11C17
Mailing Address - Street 2:EISENHOWER ARMY MEDICAL CENTER
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5650
Mailing Address - Country:US
Mailing Address - Phone:706-787-4657
Mailing Address - Fax:706-787-1745
Practice Address - Street 1:300 W HOSPITAL ROAD, ROOM 11C17 ATTN: OFFICE OF GME
Practice Address - Street 2:EISENHOWER ARMY MEDICAL CENTER
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5650
Practice Address - Country:US
Practice Address - Phone:706-787-4657
Practice Address - Fax:706-787-1745
Is Sole Proprietor?:No
Enumeration Date:2008-08-03
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA63653207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAVAD 000Medicare UPIN