Provider Demographics
NPI:1821431560
Name:EVANS, MATT (MD)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MATTHEW
Other - Middle Name:DOUGLAS
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3060 N RIDGECREST UNIT 161
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-1081
Mailing Address - Country:US
Mailing Address - Phone:480-332-9227
Mailing Address - Fax:
Practice Address - Street 1:1209 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85003-2692
Practice Address - Country:US
Practice Address - Phone:602-258-6797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-11
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ548172083A0300X, 207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ322863Medicaid
R189324Medicare PIN