Provider Demographics
NPI:1881986982
Name:LACEFIELD, EVAN
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:LACEFIELD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 E 29TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2507
Mailing Address - Country:US
Mailing Address - Phone:979-774-3041
Mailing Address - Fax:979-774-3053
Practice Address - Street 1:2700 E 29TH ST STE 100
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2507
Practice Address - Country:US
Practice Address - Phone:979-774-3041
Practice Address - Fax:979-774-3053
Is Sole Proprietor?:No
Enumeration Date:2011-05-07
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ7572208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1881986982OtherUROLOGY
TX358172001Medicaid