Provider Demographics
NPI:1740381185
Name:OBRIEN, EVAN D (MD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:D
Last Name:OBRIEN
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 1:1225 N BROAD ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WEST DEPTFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-1203
Mailing Address - Country:US
Mailing Address - Phone:856-845-0707
Mailing Address - Fax:856-845-0082
Practice Address - Street 1:1225 N BROAD ST
Practice Address - Street 2:SUITE 3
Practice Address - City:WEST DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08096-1203
Practice Address - Country:US
Practice Address - Phone:856-845-0707
Practice Address - Fax:856-845-0082
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA63525207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2003795000OtherKEYSTONE HEALTH PLAN EAST
NJ232764000OtherHORIZON
NJ2003795000OtherAMERIHEALTH
NJ2003795000OtherKEYSTONE HEALTH PLAN EAST
NJ050893Medicare ID - Type Unspecified