Provider Demographics
NPI:1821101742
Name:ALLEN, EVAN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:DAVID
Last Name:ALLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:13506 SUMMERPORT VILLAGE PKWY # 413
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-7366
Mailing Address - Country:US
Mailing Address - Phone:407-902-5987
Mailing Address - Fax:
Practice Address - Street 1:1000 N WESTMORELAND RD # LEVEL3
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1658
Practice Address - Country:US
Practice Address - Phone:847-535-8500
Practice Address - Fax:847-535-8499
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG887202084N0400X
KY464142084N0400X
MI43015047042084N0400X
IN01072076A2084N0400X
FLME824522084N0400X
IL0361081652084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100756660Medicaid
IN201374230Medicaid