Provider Demographics
NPI:1992862148
Name:EVANS, JASON MARION (OD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:MARION
Last Name:EVANS
Suffix:
Gender:M
Credentials:OD
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 1301
Mailing Address - Street 2:
Mailing Address - City:INEZ
Mailing Address - State:KY
Mailing Address - Zip Code:41224-1301
Mailing Address - Country:US
Mailing Address - Phone:606-789-0343
Mailing Address - Fax:606-788-7342
Practice Address - Street 1:470 N MAYO TRL
Practice Address - Street 2:
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240-1806
Practice Address - Country:US
Practice Address - Phone:606-789-0343
Practice Address - Fax:606-788-7342
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1637DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77001410Medicaid
KYV05948Medicare UPIN
KY77001410Medicaid