Provider Demographics
NPI:1427553577
Name:MONSON, EVAN (MD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:MONSON
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 1:3240 AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-6320
Mailing Address - Country:US
Mailing Address - Phone:770-860-1133
Mailing Address - Fax:770-860-1599
Practice Address - Street 1:3240 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-6320
Practice Address - Country:US
Practice Address - Phone:770-860-1133
Practice Address - Fax:770-860-1599
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA93322207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0116031925OtherVIRGINIA DEPARTMENT OF HEALTH PROFESSIONS