Provider Demographics
NPI:1407197684
Name:EVANS, SAMUEL CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:CHARLES
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 1100
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-1100
Mailing Address - Country:US
Mailing Address - Phone:417-256-9111
Mailing Address - Fax:417-257-5947
Practice Address - Street 1:181 N KENTUCKY AVE STE 100
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-2092
Practice Address - Country:US
Practice Address - Phone:417-257-5911
Practice Address - Fax:417-257-5913
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-12
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-8117207QA0505X
MO2020012799207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200084697Medicaid
MO2020012799OtherSTATE LICENSE