Provider Demographics
NPI:1285644302
Name:ANDERSON, EVANGELA L (DPM)
Entity Type:Individual
Prefix:
First Name:EVANGELA
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 S FLEISHEL AVE
Mailing Address - Street 2:STE. 301
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-3388
Mailing Address - Country:US
Mailing Address - Phone:903-593-6104
Mailing Address - Fax:903-597-8931
Practice Address - Street 1:1407 S FLEISHEL AVE
Practice Address - Street 2:STE. 301
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-3388
Practice Address - Country:US
Practice Address - Phone:903-593-6104
Practice Address - Fax:903-597-8931
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1534213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4484180001Medicare NSC
00255PMedicare PIN
TXU85460Medicare UPIN