Provider Demographics
NPI:1598847253
Name:EVANS, SR JR (MD)
Entity Type:Individual
Prefix:
First Name:SR
Middle Name:
Last Name:EVANS
Suffix:JR
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 1:1604 LEFLORE AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930
Mailing Address - Country:US
Mailing Address - Phone:662-453-0532
Mailing Address - Fax:662-453-3079
Practice Address - Street 1:1604 LEFLORE AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930
Practice Address - Country:US
Practice Address - Phone:662-453-0532
Practice Address - Fax:662-453-3079
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS04978207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125971Medicaid
MS020052768OtherRAILROAD MEDICARE
B31021Medicare UPIN
MS00125971Medicaid