Provider Demographics
NPI:1336367226
Name:EVRA, EUGENE (MD)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:EVRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:YEVGENIY
Other - Middle Name:
Other - Last Name:YEVRAYEV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11365 DORSETT RD.
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043
Mailing Address - Country:US
Mailing Address - Phone:314-872-6430
Mailing Address - Fax:314-872-6500
Practice Address - Street 1:11365 DORSETT RD.
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043
Practice Address - Country:US
Practice Address - Phone:314-872-6430
Practice Address - Fax:314-872-6500
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOBB4745785208100000X
MO2008009812208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1336367226Medicaid