Provider Demographics
NPI:1346260247
Name:BLACK, EVAN GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:GEORGE
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5323 WOODROW ST
Mailing Address - Street 2:#201
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5841
Mailing Address - Country:US
Mailing Address - Phone:801-261-4711
Mailing Address - Fax:801-261-4769
Practice Address - Street 1:5323 WOODROW ST
Practice Address - Street 2:#201
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5841
Practice Address - Country:US
Practice Address - Phone:801-261-4711
Practice Address - Fax:801-261-4769
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD4761842084N0400X
UT187597-12052084N0400X
NH216192084N0400X
MT996222084N0400X
GA891912084N0400X
ORMD2057382084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005812301Medicare PIN
G02584Medicare UPIN