Provider Demographics
NPI:1801819172
Name:M BRADLEY EVANS MD PA
Entity Type:Organization
Organization Name:M BRADLEY EVANS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-420-7212
Mailing Address - Street 1:324 W MAIN ST
Mailing Address - Street 2:100
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-3866
Mailing Address - Country:US
Mailing Address - Phone:972-420-7212
Mailing Address - Fax:972-420-8812
Practice Address - Street 1:324 W MAIN ST
Practice Address - Street 2:100
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-3866
Practice Address - Country:US
Practice Address - Phone:972-420-7212
Practice Address - Fax:972-420-8812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00W968Medicare PIN