Provider Demographics
NPI:1770746828
Name:RAE, EVAN ALEXANDER (DO)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:ALEXANDER
Last Name:RAE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:26908 DETROIT RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-2398
Mailing Address - Country:US
Mailing Address - Phone:440-617-1823
Mailing Address - Fax:
Practice Address - Street 1:26908 DETROIT RD
Practice Address - Street 2:SUITE 201
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-2398
Practice Address - Country:US
Practice Address - Phone:440-777-3500
Practice Address - Fax:440-871-6726
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-010017207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0050259Medicaid
OH0050259Medicaid
OHH016520Medicare PIN