Provider Demographics
NPI:1922074384
Name:SUMMERS, EVAN L (DO)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:L
Last Name:SUMMERS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 405827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5827
Mailing Address - Country:US
Mailing Address - Phone:901-227-4068
Mailing Address - Fax:228-575-7420
Practice Address - Street 1:2301 SOUTH LAMAR BLVD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655
Practice Address - Country:US
Practice Address - Phone:662-232-8568
Practice Address - Fax:662-513-1450
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16638207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121440Medicaid
MS02453398Medicaid
MS512I110312Medicare PIN
G71116Medicare UPIN
MS02453398Medicaid
MS110002035Medicare PIN
302I118507Medicare PIN