Provider Demographics
NPI:1881761252
Name:THEOHARIS, EVAN T (MD)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:T
Last Name:THEOHARIS
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-7130
Mailing Address - Fax:239-343-7185
Practice Address - Street 1:9800 S HEALTHPARK DR STE 205
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3630
Practice Address - Country:US
Practice Address - Phone:239-343-7130
Practice Address - Fax:239-343-7185
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME164423207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI316389710Medicaid
ET057938OtherCOMMERCIAL-COMMERCIAL NUMBER
FL119330700Medicaid
700H262210OtherBLUE CROSS-BLUE CROSS
ET057938OtherCHAMPUS-CHAMPUS
700H262210OtherBLUE CROSS-BLUE CROSS