Provider Demographics
NPI:1144231887
Name:EVANS, PHILLIP T (DO)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:T
Last Name:EVANS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11219
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-0219
Mailing Address - Country:US
Mailing Address - Phone:817-294-7444
Mailing Address - Fax:817-294-7172
Practice Address - Street 1:12001 S. FWY
Practice Address - Street 2:SUITE 101
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028
Practice Address - Country:US
Practice Address - Phone:817-615-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF8857207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00840ZMedicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
TXC15527Medicare UPIN