Provider Demographics
NPI:1982643797
Name:JONES, EVELYN MONTGOMERY (MD)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:MONTGOMERY
Last Name:JONES
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 1:2721 W PARK DR
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-9058
Mailing Address - Country:US
Mailing Address - Phone:270-554-7540
Mailing Address - Fax:270-554-0316
Practice Address - Street 1:2721 W PARK DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-9058
Practice Address - Country:US
Practice Address - Phone:270-554-7540
Practice Address - Fax:270-554-0316
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY27324207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000324645OtherANTHEM
KYP00080586OtherRAILROAD MEDICARE
KYF39495Medicare UPIN
KY7958Medicare ID - Type Unspecified
KY0795801Medicare PIN