Provider Demographics
NPI:1467454488
Name:EVANS, EVAN C (OD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:C
Last Name:EVANS
Suffix:
Gender:M
Credentials:OD
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 147
Mailing Address - Street 2:
Mailing Address - City:AINSWORTH
Mailing Address - State:NE
Mailing Address - Zip Code:69210-0147
Mailing Address - Country:US
Mailing Address - Phone:402-387-1531
Mailing Address - Fax:402-387-1106
Practice Address - Street 1:305 N MAIN ST
Practice Address - Street 2:
Practice Address - City:AINSWORTH
Practice Address - State:NE
Practice Address - Zip Code:69210-1355
Practice Address - Country:US
Practice Address - Phone:402-387-1531
Practice Address - Fax:402-387-1106
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE785152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47054389501Medicaid
NE0310690001Medicare NSC
NE410006512Medicare PIN
NET40268Medicare UPIN