Provider Demographics
NPI:1578979647
Name:EVANS, BRYANT C (OD)
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:C
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 1:601 PERIMETER DR
Mailing Address - Street 2:STE 200
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-4121
Mailing Address - Country:US
Mailing Address - Phone:859-278-9393
Mailing Address - Fax:859-278-0923
Practice Address - Street 1:601 PERIMETER DR
Practice Address - Street 2:STE 200
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-4121
Practice Address - Country:US
Practice Address - Phone:859-278-9393
Practice Address - Fax:859-278-0923
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1966DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100312180Medicaid
KYK156562Medicare PIN
KYK156560Medicare PIN
KY7100312180Medicaid