Provider Demographics
NPI:1235126491
Name:EVANS, ELIZABETH YVONNE (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:YVONNE
Last Name:EVANS
Suffix:
Gender:F
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:PO BOX 681946
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-0032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 COTTAGE GROVE RD
Practice Address - Street 2:C130
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-0323
Practice Address - Country:US
Practice Address - Phone:860-243-3352
Practice Address - Fax:860-243-3329
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036156671207R00000X
CT040729207R00000X
GA80610207R00000X
NC2018-01819207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTH95811Medicare UPIN
CT110009044Medicare PIN