Provider Demographics
NPI:1972658078
Name:DVORIN, EVAN L (MD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:L
Last Name:DVORIN
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 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4747
Mailing Address - Fax:
Practice Address - Street 1:1514 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70121-2429
Practice Address - Country:US
Practice Address - Phone:504-842-4747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA232540207R00000X
LAMD.205481207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08103831Medicaid
LA2197479Medicaid
LA4R0987061Medicare PIN