Provider Demographics
NPI:1033175781
Name:EVANS, JACK L (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:L
Last Name:EVANS
Suffix:
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 1:32 WALKER ST
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-3030
Mailing Address - Country:US
Mailing Address - Phone:419-842-4336
Mailing Address - Fax:
Practice Address - Street 1:629 N SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:BUCYRUS
Practice Address - State:OH
Practice Address - Zip Code:44820-1821
Practice Address - Country:US
Practice Address - Phone:419-562-4677
Practice Address - Fax:419-562-0987
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35044381207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000382640OtherBCBS
POO328458OtherRAILROAD MEDICARE
OH0464180Medicaid
OH000000316691OtherBCBS # FOR BUCYRUS
OH0464180Medicaid
OH000000382640OtherBCBS