Provider Demographics
NPI:1093714503
Name:EVANOFF, JOHN C JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:EVANOFF
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 1:1990 COUNTRY RD U
Mailing Address - Street 2:
Mailing Address - City:METAMORA
Mailing Address - State:OH
Mailing Address - Zip Code:43540
Mailing Address - Country:US
Mailing Address - Phone:419-644-4818
Mailing Address - Fax:419-644-2589
Practice Address - Street 1:1990 COUNTRY RD U
Practice Address - Street 2:
Practice Address - City:METAMORA
Practice Address - State:OH
Practice Address - Zip Code:43540
Practice Address - Country:US
Practice Address - Phone:419-644-4818
Practice Address - Fax:419-644-2589
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35059829207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH01-03360OtherUHC
OH0791586Medicaid
OH0635152OtherAETNA
OH080120479OtherRRMC
OH000000141243OtherANTHEM
OH02035OtherPARAMOUNT
OH080120479OtherRRMC
OHE75531Medicare UPIN
OH0791586Medicaid