Provider Demographics
NPI:1598837429
Name:FOX, EVAN (MD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:FOX
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 1:300 HEBRON AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033
Mailing Address - Country:US
Mailing Address - Phone:860-430-1150
Mailing Address - Fax:860-430-1093
Practice Address - Street 1:300 HEBRON AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033
Practice Address - Country:US
Practice Address - Phone:860-430-1150
Practice Address - Fax:860-430-1093
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0311922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
F17848Medicare UPIN