Provider Demographics
NPI:1851394175
Name:EVANOFF, VAN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:VAN
Middle Name:
Last Name:EVANOFF
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2204 N SECTION ST PO BOX 10
Mailing Address - Street 2:SUITE B
Mailing Address - City:SULLIVAN
Mailing Address - State:IN
Mailing Address - Zip Code:47882-0010
Mailing Address - Country:US
Mailing Address - Phone:812-268-2556
Mailing Address - Fax:812-268-2652
Practice Address - Street 1:2204 N SECTION ST
Practice Address - Street 2:SUITE B
Practice Address - City:SULLIVAN
Practice Address - State:IN
Practice Address - Zip Code:47882-0010
Practice Address - Country:US
Practice Address - Phone:812-268-2556
Practice Address - Fax:812-268-2652
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053652A208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000338733OtherBLUE CROSS & BLUE SHIELD
IN200262220Medicaid
INP01625340OtherRAILROAD MEDICARE
IN218940AMedicare PIN
IN000000338733OtherBLUE CROSS & BLUE SHIELD
INP01625340OtherRAILROAD MEDICARE