Provider Demographics
NPI:1194002394
Name:J. DAVID EVANICH, M.D. PA
Entity Type:Organization
Organization Name:J. DAVID EVANICH, M.D. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:EVANICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-420-1776
Mailing Address - Street 1:5000 LONG PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-2783
Mailing Address - Country:US
Mailing Address - Phone:972-420-1776
Mailing Address - Fax:972-221-8685
Practice Address - Street 1:1234 FM 407
Practice Address - Street 2:STE 100
Practice Address - City:NORTH LAKE
Practice Address - State:TX
Practice Address - Zip Code:76226
Practice Address - Country:US
Practice Address - Phone:972-420-1776
Practice Address - Fax:972-221-8685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-16
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2878207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4224610001Medicare NSC
TX170524601Medicaid
TX00402XMedicare PIN