Provider Demographics
NPI:1831215185
Name:EVANS, FREDERICK WILLIAM (DC)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:WILLIAM
Last Name:EVANS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8404 SPRUCE HILL RD
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-7402
Mailing Address - Country:US
Mailing Address - Phone:502-749-8825
Mailing Address - Fax:502-749-8826
Practice Address - Street 1:3071 BRECKENRIDGE LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-2101
Practice Address - Country:US
Practice Address - Phone:502-459-4150
Practice Address - Fax:502-459-4662
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4122111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2437566000Medicare UPIN
KY62178Medicare UPIN
KY1129511Medicare ID - Type UnspecifiedPASSPORT
KY0629804Medicare ID - Type Unspecified