Provider Demographics
NPI:1568460640
Name:EVANS, JONATHAN G (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:G
Last Name:EVANS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JONATHAN
Other - Middle Name:G
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3443 DICKERSON PIKE
Mailing Address - Street 2:SUITE 680
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37207-2519
Mailing Address - Country:US
Mailing Address - Phone:615-865-3322
Mailing Address - Fax:615-467-6692
Practice Address - Street 1:100 FODEN RD STE 103
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2327
Practice Address - Country:US
Practice Address - Phone:207-828-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD27860207RP1001X
TN24656207RS0012X
TNMD0000024656207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN621632725OtherTAX ID
KY64014905Medicaid
TN3076519Medicaid
TN621701777OtherTAX ID
TN621701777OtherTAX ID