Provider Demographics
NPI:1093756736
Name:EVANS, BOOKER THEODORE (MD)
Entity Type:Individual
Prefix:DR
First Name:BOOKER
Middle Name:THEODORE
Last Name:EVANS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:225 WENDELL ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:FAIR BANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701
Mailing Address - Country:US
Mailing Address - Phone:907-455-4140
Mailing Address - Fax:907-455-4119
Practice Address - Street 1:225 WENDELL ST
Practice Address - Street 2:SUITE B
Practice Address - City:FAIR BANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:907-455-4140
Practice Address - Fax:907-455-4119
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZAK44332084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ING73883Medicare UPIN
651990RMedicare UPIN