Provider Demographics
NPI:1568439057
Name:EVANS, BENJAMIN F (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:F
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 1:1264 WESLEY DR
Mailing Address - Street 2:STE 206
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-6444
Mailing Address - Country:US
Mailing Address - Phone:901-346-6566
Mailing Address - Fax:
Practice Address - Street 1:1264 WESLEY DR
Practice Address - Street 2:#206
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6400
Practice Address - Country:US
Practice Address - Phone:901-346-6566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD019874207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3045719Medicaid
TN99977OtherBCBST
TN3703296Medicaid
TN3045719Medicaid
TN3703296Medicaid
TN3045719Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE