Provider Demographics
NPI:1952494122
Name:EVANS, LISA SMITH (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:SMITH
Last Name:EVANS
Suffix:
Gender:F
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 30337
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27130-0337
Mailing Address - Country:US
Mailing Address - Phone:336-718-8592
Mailing Address - Fax:336-718-9269
Practice Address - Street 1:3333 SILAS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3013
Practice Address - Country:US
Practice Address - Phone:336-718-5095
Practice Address - Fax:336-718-9895
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC378242085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC30913OtherBLUECROSS/ BLUESHIELD
NC7930913Medicaid
VA5860342Medicaid
97951OtherMEDCOST
0194185006OtherCIGNA HEALTHCARE
2790OtherPARTNERS NATIONAL HEALTH
2408400OtherUNITED HEALTH CARE
NC30913OtherBLUECROSS/ BLUESHIELD
2790OtherPARTNERS NATIONAL HEALTH
2142966BMedicare ID - Type Unspecified