Provider Demographics
NPI:1669097184
Name:EVANS, MICHAEL DEE ANTHONY (CSTFA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DEE ANTHONY
Last Name:EVANS
Suffix:
Gender:M
Credentials:CSTFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 S BROWN SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-3051
Mailing Address - Country:US
Mailing Address - Phone:937-776-7172
Mailing Address - Fax:
Practice Address - Street 1:7777 YANKEE RD
Practice Address - Street 2:
Practice Address - City:LIBERTY TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45044-3500
Practice Address - Country:US
Practice Address - Phone:513-803-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH31581992086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery