Provider Demographics
NPI:1831325356
Name:EVANS, KENDRIX JERMAINE (MD)
Entity type:Individual
Prefix:
First Name:KENDRIX
Middle Name:JERMAINE
Last Name:EVANS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-2609
Practice Address - Street 1:1811 EDWINA DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8963
Practice Address - Country:US
Practice Address - Phone:912-538-9977
Practice Address - Fax:912-538-0770
Is Sole Proprietor?:No
Enumeration Date:2009-06-10
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8406595-1205208600000X
LA301950208600000X
MS21459208600000X
390200000X
GA83679208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08771565Medicaid
LA2427458Medicaid
GA003221715AMedicaid