Provider Demographics
NPI:1164470035
Name:EVANS, EDWARD E (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:E
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 1:15 MADISON PROFESSIONAL PARK
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2057
Mailing Address - Country:US
Mailing Address - Phone:208-356-6185
Mailing Address - Fax:208-356-0378
Practice Address - Street 1:15 MADISON PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2057
Practice Address - Country:US
Practice Address - Phone:208-356-6185
Practice Address - Fax:208-356-0378
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM10591207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808292100Medicaid
ID00001017396OtherBLUE SHIELD
ID77955OtherBLUE CROSS
ID808292100Medicaid
IDF65976Medicare UPIN
ID00001017396OtherBLUE SHIELD