Provider Demographics
NPI:1629284195
Name:EVANS, ROBERT (DC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 MARKET STREET
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07513-1235
Mailing Address - Country:US
Mailing Address - Phone:973-742-1177
Mailing Address - Fax:973-742-6031
Practice Address - Street 1:726 MARKET ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07513-1235
Practice Address - Country:US
Practice Address - Phone:973-742-1177
Practice Address - Fax:973-742-6031
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00221500111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3314901Medicaid
NJ511534Medicare PIN