Provider Demographics
NPI:1093708257
Name:EVANS, RAYMOND C (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:C
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 1:901 18TH ST E
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3648
Mailing Address - Country:US
Mailing Address - Phone:912-287-1515
Mailing Address - Fax:912-287-1394
Practice Address - Street 1:901 18TH ST E
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3648
Practice Address - Country:US
Practice Address - Phone:912-287-1515
Practice Address - Fax:912-287-1394
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2007-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0234502085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA30CDBFFMedicare ID - Type Unspecified
GAE89460Medicare UPIN