Provider Demographics
NPI:1275561540
Name:EVANS, EDMOND C JR (DO)
Entity Type:Individual
Prefix:
First Name:EDMOND
Middle Name:C
Last Name:EVANS
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SW 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:MINERAL WELLS
Mailing Address - State:TX
Mailing Address - Zip Code:76067-8246
Mailing Address - Country:US
Mailing Address - Phone:940-325-7891
Mailing Address - Fax:940-328-6523
Practice Address - Street 1:400 SW 25TH AVE
Practice Address - Street 2:
Practice Address - City:MINERAL WELLS
Practice Address - State:TX
Practice Address - Zip Code:76067-8246
Practice Address - Country:US
Practice Address - Phone:940-325-7891
Practice Address - Fax:940-328-6523
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD4484207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX033822002Medicaid
TX8U9490OtherBCBS
TX8U9490OtherBCBS
TXD83795Medicare UPIN