Provider Demographics
NPI:1780843003
Name:EVANS, VIRDEN (DO)
Entity Type:Individual
Prefix:DR
First Name:VIRDEN
Middle Name:
Last Name:EVANS
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 1:1607 ST. JAMES COURT
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-0001
Mailing Address - Country:US
Mailing Address - Phone:850-878-0191
Mailing Address - Fax:
Practice Address - Street 1:1607 ST. JAMES COURT
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-0001
Practice Address - Country:US
Practice Address - Phone:850-878-0191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213070207Q00000X
CA20A10180207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH24681Medicare UPIN