Provider Demographics
NPI:1114478419
Name:EVANS, JERRY JOE (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:JOE
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 1:610 W OTTAWA ST
Mailing Address - Street 2:APT. 906
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48933-1056
Mailing Address - Country:US
Mailing Address - Phone:231-631-5642
Mailing Address - Fax:
Practice Address - Street 1:610 W OTTAWA ST
Practice Address - Street 2:APT. 906
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48933-1056
Practice Address - Country:US
Practice Address - Phone:231-631-5642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301029922208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics