Provider Demographics
NPI:1942281688
Name:EVANS, PERRY WILLIAM JR (DO)
Entity Type:Individual
Prefix:DR
First Name:PERRY
Middle Name:WILLIAM
Last Name:EVANS
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:119 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OK
Mailing Address - Zip Code:74020-4614
Mailing Address - Country:US
Mailing Address - Phone:918-358-2592
Mailing Address - Fax:918-358-3133
Practice Address - Street 1:119 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OK
Practice Address - Zip Code:74020-4614
Practice Address - Country:US
Practice Address - Phone:918-358-2592
Practice Address - Fax:918-358-3133
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK1856207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100116960AMedicaid
731508405OtherORG EIN
OK100116960AMedicaid