Provider Demographics
NPI:1336123124
Name:EVAN, MICHAEL BOGAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BOGAN
Last Name:EVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6615 CLINGAN ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-4202
Mailing Address - Country:US
Mailing Address - Phone:330-707-1425
Mailing Address - Fax:330-757-2814
Practice Address - Street 1:6615 CLINGAN ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:POLAND
Practice Address - State:OH
Practice Address - Zip Code:44514-4202
Practice Address - Country:US
Practice Address - Phone:330-707-1425
Practice Address - Fax:330-757-2814
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35053782207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0778967Medicaid
OH35053782OtherLICENSE
OHE41711Medicare UPIN
OHEV0665081Medicare ID - Type Unspecified