Provider Demographics
NPI:1093704306
Name:EVANS, JASON ANTHONY (DPM)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:ANTHONY
Last Name:EVANS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 E COMMERCIAL BLVD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4229
Mailing Address - Country:US
Mailing Address - Phone:954-776-5700
Mailing Address - Fax:954-776-5701
Practice Address - Street 1:2800 E COMMERCIAL BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4229
Practice Address - Country:US
Practice Address - Phone:954-776-5700
Practice Address - Fax:954-776-5701
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2016-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2835213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340316500Medicaid
FLAA746AMedicare PIN
FL340316500Medicaid