Provider Demographics
NPI:1669634143
Name:PIKE, EVAN C (MD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:C
Last Name:PIKE
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 1:8921 N WOOD SAGE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-7822
Mailing Address - Country:US
Mailing Address - Phone:309-243-2400
Mailing Address - Fax:
Practice Address - Street 1:8921 N WOOD SAGE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-7822
Practice Address - Country:US
Practice Address - Phone:309-243-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35099461207W00000X
IL036132250207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0068330Medicaid
OHH180980Medicare PIN