Provider Demographics
NPI:1164506465
Name:PHILLIPS, EVAN ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:ALAN
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11225 NALL AVE
Mailing Address - Street 2:STE. 100
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1669
Mailing Address - Country:US
Mailing Address - Phone:913-345-8020
Mailing Address - Fax:913-338-5483
Practice Address - Street 1:11225 NALL AVE
Practice Address - Street 2:STE. 100
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1669
Practice Address - Country:US
Practice Address - Phone:913-345-8020
Practice Address - Fax:913-338-5483
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1638152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSU83045Medicare UPIN
KSN74C280Medicare ID - Type Unspecified