Provider Demographics
NPI:1922162924
Name:EVANS, GEORGE EDWARD (DO)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:EDWARD
Last Name:EVANS
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 1:2950 E JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-4208
Mailing Address - Country:US
Mailing Address - Phone:313-567-3550
Mailing Address - Fax:313-567-2905
Practice Address - Street 1:2950 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4208
Practice Address - Country:US
Practice Address - Phone:313-567-3550
Practice Address - Fax:313-567-2905
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007577207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI429667834Medicaid
MI429667834Medicaid