Provider Demographics
NPI:1295820116
Name:EVANS, DOUGLAS B (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:B
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 1:9200 W WISCONSIN AVENUE
Mailing Address - Street 2:SURGICAL ONCOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-5020
Mailing Address - Fax:414-805-5771
Practice Address - Street 1:9200 W WISCONSIN AVENUE
Practice Address - Street 2:SURGICAL ONCOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-5020
Practice Address - Fax:414-805-5771
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH55462086X0206X
WI524982086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX36457201Medicaid
WI1295820116Medicaid
WI1295820116Medicaid
TX36457201Medicaid
WI736011336Medicare PIN