Provider Demographics
NPI:1295733772
Name:EVANS, RANDOLPH R (MD)
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:R
Last Name:EVANS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1670 W MAIN ST
Mailing Address - Street 2:STE100
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-1344
Mailing Address - Country:US
Mailing Address - Phone:615-453-5155
Mailing Address - Fax:615-444-5915
Practice Address - Street 1:1670 W MAIN ST
Practice Address - Street 2:STE100
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-1344
Practice Address - Country:US
Practice Address - Phone:615-453-5155
Practice Address - Fax:615-444-5915
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2012-08-17
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Provider Licenses
StateLicense IDTaxonomies
TN18805207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4065401OtherAETNA PPO
TN1238610001OtherDMERC
TN180006421OtherPALMETTO GBA
TN000089791OtherBCBS ADVANTAGE
TN3032849OtherHEALTHSPRING
TN000089791OtherBLUE CROSS BLUE SHIELD
TN3389788Medicaid
TN621298175OtherDEFAULT
TN000089791OtherTENNCARE SELECT
TN186641053OtherVISION SERVICE PLAN
TN1238610001OtherDMERC
TN4065401OtherAETNA PPO