Provider Demographics
NPI:1831263375
Name:EVANS, LAURA R (OD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:R
Last Name:EVANS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3230 BLATTNER DR.
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-6380
Mailing Address - Country:US
Mailing Address - Phone:573-334-2020
Mailing Address - Fax:573-334-2915
Practice Address - Street 1:3230 BLATTNER DR.
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-6380
Practice Address - Country:US
Practice Address - Phone:573-334-2020
Practice Address - Fax:573-334-2915
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03451152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO314852815Medicaid
MOU78484Medicare UPIN
MO000091385Medicare ID - Type Unspecified