Provider Demographics
NPI:1669497236
Name:EVANKO, MARK (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:EVANKO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3428 STATE HIGHWAY 47
Mailing Address - Street 2:SUITE C
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-8271
Mailing Address - Country:US
Mailing Address - Phone:505-565-2817
Mailing Address - Fax:505-565-2411
Practice Address - Street 1:7601 JEFFERSON ST NE
Practice Address - Street 2:SUITE 340
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4494
Practice Address - Country:US
Practice Address - Phone:505-338-3851
Practice Address - Fax:505-338-3859
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA87488207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E15926Medicare UPIN