Provider Demographics
NPI:1790781797
Name:EVANS, STANLEY (DO)
Entity Type:Individual
Prefix:
First Name:STANLEY
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 1:3105 COLORADO BLVD
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-6887
Mailing Address - Country:US
Mailing Address - Phone:940-383-3444
Mailing Address - Fax:940-383-2224
Practice Address - Street 1:3105 COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-6887
Practice Address - Country:US
Practice Address - Phone:940-383-3444
Practice Address - Fax:940-383-2224
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1993207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092200701Medicaid
TXDOJ1993OtherWORKERS COMP PROVIDER ID
TX752696679OtherTAX ID #
TX00J74EOtherBCBS PROVIDER #
TXDOJ1993OtherWORKERS COMP PROVIDER ID
TX092200701Medicaid