Provider Demographics
NPI:1255334538
Name:EVANS, CHARLES ALEXANDER (M D)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ALEXANDER
Last Name:EVANS
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 CHRISTIE ST.
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904
Mailing Address - Country:US
Mailing Address - Phone:936-699-5433
Mailing Address - Fax:936-699-5465
Practice Address - Street 1:203 CHRISTIE ST.
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904
Practice Address - Country:US
Practice Address - Phone:936-699-5433
Practice Address - Fax:936-699-5465
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3094207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123490806Medicaid
TX179637701Medicaid
TXBCBSOther0066MT
TXJ3094OtherSTATE MEDICAL LICENSE
TXP00310208Medicare ID - Type UnspecifiedRR MEDICARE INDIV PROV#
TX8F2949Medicare ID - Type UnspecifiedMCARE INDIVIDUAL PROV #
TXBCBSOther0066MT
TXJ3094OtherSTATE MEDICAL LICENSE
TX123490806Medicaid