Provider Demographics
NPI:1225077803
Name:EVANS, BRAD A (DO)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:A
Last Name:EVANS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 636256
Mailing Address - Street 2:CENTRAL CREDENTIALING
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-585-5505
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:7700 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-2505
Practice Address - Country:US
Practice Address - Phone:513-298-7325
Practice Address - Fax:513-298-7406
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008200207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100137860Medicaid
IN201002000Medicaid
OH2583548Medicaid
IN201002000Medicaid