Provider Demographics
NPI:1174842348
Name:LOS, EVAN (EVAN LOS, MD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:LOS
Suffix:
Gender:M
Credentials:EVAN LOS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 N STATE OF FRANKLIN RD
Mailing Address - Street 2:SUITE 31B
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6089
Mailing Address - Country:US
Mailing Address - Phone:423-431-4946
Mailing Address - Fax:423-431-4947
Practice Address - Street 1:408 N STATE OF FRANKLIN RD
Practice Address - Street 2:SUITE 31B
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6089
Practice Address - Country:US
Practice Address - Phone:423-431-4946
Practice Address - Fax:423-431-4947
Is Sole Proprietor?:No
Enumeration Date:2010-05-26
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN54336208000000X, 2080P0205X
ORMD163055208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1174842348Medicaid
TNQ022585Medicaid
TN103I378626Medicare PIN