Provider Demographics
NPI:1659531408
Name:KULBACKI, EVAN LOREN (MD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:LOREN
Last Name:KULBACKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2175 HIGHWAY 75
Mailing Address - Street 2:SUITE 4
Mailing Address - City:BLOUNTVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37617
Mailing Address - Country:US
Mailing Address - Phone:423-323-5290
Mailing Address - Fax:423-323-5653
Practice Address - Street 1:130 W RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3837
Practice Address - Country:US
Practice Address - Phone:423-224-6711
Practice Address - Fax:423-224-6717
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN49647207ZH0000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology