Provider Demographics
NPI:1588611784
Name:FLIEGEL, EVAN J (MD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:J
Last Name:FLIEGEL
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 1:1000 HAWTHORNE AVE STE P
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2168
Mailing Address - Country:US
Mailing Address - Phone:706-546-5340
Mailing Address - Fax:706-546-5603
Practice Address - Street 1:1000 HAWTHORNE AVE STE P
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2168
Practice Address - Country:US
Practice Address - Phone:706-546-5340
Practice Address - Fax:706-546-5603
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033964207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000449677BMedicaid
GA11D0987536OtherCLIA NUMBER