Provider Demographics
NPI:1376844324
Name:EVANS, MARTIN J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:J
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 1:198 WOODSIDE DR.
Mailing Address - Street 2:
Mailing Address - City:HEWLETT
Mailing Address - State:NY
Mailing Address - Zip Code:11557
Mailing Address - Country:US
Mailing Address - Phone:516-374-1483
Mailing Address - Fax:
Practice Address - Street 1:198 WOODSIDE DR.
Practice Address - Street 2:
Practice Address - City:HEWLETT
Practice Address - State:NY
Practice Address - Zip Code:11557
Practice Address - Country:US
Practice Address - Phone:516-374-1483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072251-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
072251-1OtherNY STATE MEDICAL LIC#
6706781OtherCERTIF #