Provider Demographics
NPI:1922056266
Name:EVANICH, JOHN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:EVANICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:J.
Other - Middle Name:DAVID
Other - Last Name:EVANICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5000 LONG PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-2783
Mailing Address - Country:US
Mailing Address - Phone:972-420-1776
Mailing Address - Fax:972-436-6996
Practice Address - Street 1:5000 LONG PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028
Practice Address - Country:US
Practice Address - Phone:972-420-1776
Practice Address - Fax:972-436-6996
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2878207XS0114X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX200042050OtherRAILROAD MEDICARE
TXL2878OtherMEDICAL LICENSE
TX8AJ226OtherBLUECROSS
TX145018102Medicaid
TX4224610001Medicare NSC
TX8AJ226OtherBLUECROSS
TXL2878OtherMEDICAL LICENSE
TXH21005Medicare UPIN