Provider Demographics
NPI:1952465619
Name:EVANS, ROY D (MD)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:D
Last Name:EVANS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:BASSFIELD
Mailing Address - State:MS
Mailing Address - Zip Code:39421-0068
Mailing Address - Country:US
Mailing Address - Phone:601-943-5060
Mailing Address - Fax:601-943-5888
Practice Address - Street 1:4297 HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:BASSFIELD
Practice Address - State:MS
Practice Address - Zip Code:39421-4424
Practice Address - Country:US
Practice Address - Phone:601-943-5060
Practice Address - Fax:601-943-5888
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13317207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01456013Medicaid
MS0111136Medicaid
MSD84145Medicare UPIN
MS0111136Medicaid