Provider Demographics
NPI:1568499671
Name:EVANS, JOHN O (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:O
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 1:3200 WEST ST
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-1722
Mailing Address - Country:US
Mailing Address - Phone:585-394-1358
Mailing Address - Fax:585-394-0261
Practice Address - Street 1:3200 WEST ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1722
Practice Address - Country:US
Practice Address - Phone:585-394-1358
Practice Address - Fax:585-394-0261
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003346-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00449867Medicaid
0127100001Medicare NSC
T26151Medicare UPIN
17393BMedicare PIN