Provider Demographics
NPI:1164457941
Name:EVANS, DELLIA SALONE (OD)
Entity Type:Individual
Prefix:
First Name:DELLIA
Middle Name:SALONE
Last Name:EVANS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:DELLIA
Other - Middle Name:SALONE
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:1461 CANTON MART RD STE A
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5413
Mailing Address - Country:US
Mailing Address - Phone:601-977-0835
Mailing Address - Fax:601-977-0689
Practice Address - Street 1:1461 CANTON MART RD STE A
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5413
Practice Address - Country:US
Practice Address - Phone:601-977-0835
Practice Address - Fax:601-977-0689
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS677152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02735526Medicaid
MSU51632Medicare UPIN
MS302I418537Medicare PIN