Provider Demographics
NPI:1073537916
Name:EVANS, MICHAEL BLAKE (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BLAKE
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 1:1025 VICTORIA DR
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-5749
Mailing Address - Country:US
Mailing Address - Phone:727-734-3685
Mailing Address - Fax:
Practice Address - Street 1:1025 VICTORIA DR
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-5749
Practice Address - Country:US
Practice Address - Phone:727-734-3685
Practice Address - Fax:727-734-3685
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME44887174400000X
GA067215207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4964382Medicaid
FLME44887OtherMEDICAL LICENSE
FL08373YMedicare PIN
GA202I133428Medicare PIN