Provider Demographics
NPI:1851818959
Name:STEPHEN JAMES EVANS
Entity Type:Organization
Organization Name:STEPHEN JAMES EVANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-208-3250
Mailing Address - Street 1:2427 STANTON RD
Mailing Address - Street 2:
Mailing Address - City:NEW WOODSTOCK
Mailing Address - State:NY
Mailing Address - Zip Code:13122-9736
Mailing Address - Country:US
Mailing Address - Phone:716-208-3250
Mailing Address - Fax:
Practice Address - Street 1:918 JAMES ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2500
Practice Address - Country:US
Practice Address - Phone:315-474-1561
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-29
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY177137207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01173293Medicaid