Provider Demographics
NPI:1659507317
Name:GREGORY, EVAN WADE (MD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:WADE
Last Name:GREGORY
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 1:2511 N PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72207-3620
Mailing Address - Country:US
Mailing Address - Phone:501-280-0040
Mailing Address - Fax:
Practice Address - Street 1:2302 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-6297
Practice Address - Country:US
Practice Address - Phone:501-450-2178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-08
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-7633207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR320875YM67Medicare UPIN