Provider Demographics
NPI:1346200904
Name:EVANS, GARY T (MD)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:T
Last Name:EVANS
Suffix:
Gender:M
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 881
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:TX
Mailing Address - Zip Code:76230-0881
Mailing Address - Country:US
Mailing Address - Phone:940-872-1121
Mailing Address - Fax:940-872-3007
Practice Address - Street 1:1010 N MILL ST
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:TX
Practice Address - Zip Code:76230-3120
Practice Address - Country:US
Practice Address - Phone:940-872-1121
Practice Address - Fax:940-872-3007
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8459207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX83169BMedicare ID - Type Unspecified
TXC15523Medicare UPIN