Provider Demographics
NPI:1497728638
Name:EVERSON, FREDDIE LEE (MD)
Entity Type:Individual
Prefix:
First Name:FREDDIE
Middle Name:LEE
Last Name:EVERSON
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 405827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1520 UNION AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38174-0275
Practice Address - Country:US
Practice Address - Phone:901-276-2410
Practice Address - Fax:901-261-6010
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25353207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3088058Medicaid
TN3088058Medicaid
TN3088057Medicare ID - Type Unspecified