Provider Demographics
NPI:1568180438
Name:EVANS, DANIEL KYLE (IDC)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:KYLE
Last Name:EVANS
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10168 KEPPLER DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-2504
Mailing Address - Country:US
Mailing Address - Phone:252-503-3821
Mailing Address - Fax:
Practice Address - Street 1:EFFINGHAM ST BLDG 36
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708-7000
Practice Address - Country:US
Practice Address - Phone:757-953-4688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-17
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
1568180438OtherDOD