Provider Demographics
NPI:1821073289
Name:EVANS, RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:EVANS
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 1:20 GRAND ST
Mailing Address - Street 2:FL 3
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-1035
Mailing Address - Country:US
Mailing Address - Phone:845-777-3569
Mailing Address - Fax:845-987-5979
Practice Address - Street 1:2 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:WEST NYACK
Practice Address - State:NY
Practice Address - Zip Code:10994-1965
Practice Address - Country:US
Practice Address - Phone:845-354-5000
Practice Address - Fax:845-354-9469
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1643911208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E78224Medicare UPIN
55T491Medicare ID - Type Unspecified