Provider Demographics
NPI:1336538370
Name:EVAN EARL DUSSIA II MD PLLC
Entity Type:Organization
Organization Name:EVAN EARL DUSSIA II MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:DUSSIA
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:850-583-2926
Mailing Address - Street 1:1020 E LAFAYETTE ST
Mailing Address - Street 2:SUITE:101
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-4569
Mailing Address - Country:US
Mailing Address - Phone:850-583-2696
Mailing Address - Fax:850-792-6043
Practice Address - Street 1:1030 E LAFAYETTE ST STE 4
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-4547
Practice Address - Country:US
Practice Address - Phone:850-583-2926
Practice Address - Fax:850-792-6043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065885500Medicaid
FL065885500Medicaid