Provider Demographics
NPI:1396967097
Name:EVENSTAR INTERNAL MEDICINE PC
Entity type:Organization
Organization Name:EVENSTAR INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:TRUDY
Authorized Official - Middle Name:G
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-528-6929
Mailing Address - Street 1:6165 LEHMAN DR STE 105
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-5405
Mailing Address - Country:US
Mailing Address - Phone:719-528-6929
Mailing Address - Fax:719-528-6900
Practice Address - Street 1:6165 LEHMAN DR STE 105
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-5405
Practice Address - Country:US
Practice Address - Phone:719-528-6929
Practice Address - Fax:719-528-6900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO34645207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO15874273Medicaid
CO15874273Medicaid