Provider Demographics
NPI:1821115304
Name:OUTLAW-EVANS, ELESYIA D (MD)
Entity Type:Individual
Prefix:DR
First Name:ELESYIA
Middle Name:D
Last Name:OUTLAW-EVANS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:600 CELEBRATE LIFE PKWY
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-8001
Mailing Address - Country:US
Mailing Address - Phone:770-343-7735
Mailing Address - Fax:770-400-6925
Practice Address - Street 1:600 CELEBRATE LIFE PKWY
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-8001
Practice Address - Country:US
Practice Address - Phone:770-400-6349
Practice Address - Fax:770-400-6349
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20042085R0001X
LA2051772085R0001X
AL354352085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2187741Medicaid
LA4Q961Medicare PIN