Provider Demographics
NPI:1013013960
Name:EVANS, THOMAS CHARLES JR (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:CHARLES
Last Name:EVANS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 HILLSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-7570
Mailing Address - Country:US
Mailing Address - Phone:601-249-0943
Mailing Address - Fax:
Practice Address - Street 1:1023 HILLSHIRE DR
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-7570
Practice Address - Country:US
Practice Address - Phone:601-249-0943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA03561R207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1148041Medicaid
LAB63108Medicare UPIN
LA1148041Medicaid