Provider Demographics
NPI:1639141187
Name:EVAN, STEPHEN JOHN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JOHN
Last Name:EVAN
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 1:7645 MARKET ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-6098
Mailing Address - Country:US
Mailing Address - Phone:330-707-0771
Mailing Address - Fax:
Practice Address - Street 1:7645 MARKET ST
Practice Address - Street 2:SUITE 200
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-6098
Practice Address - Country:US
Practice Address - Phone:330-707-0771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067701208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH311549684OtherOHIO BWC
OH0270264Medicaid
OHEV0822621Medicare ID - Type Unspecified
G50677Medicare UPIN