Provider Demographics
NPI:1265752356
Name:EVANS, JOHN ELLIS (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ELLIS
Last Name:EVANS
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 1:404 JENNINGS ST
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:MS
Mailing Address - Zip Code:38957-9720
Mailing Address - Country:US
Mailing Address - Phone:321-720-0574
Mailing Address - Fax:
Practice Address - Street 1:456 RIVER ROAD
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MS
Practice Address - Zip Code:39069
Practice Address - Country:US
Practice Address - Phone:601-786-0443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-11
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05736207Q00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery