Provider Demographics
NPI:1932194644
Name:EVANCHO, CHARLES DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DAVID
Last Name:EVANCHO
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 750
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18501-0750
Mailing Address - Country:US
Mailing Address - Phone:570-346-7797
Mailing Address - Fax:570-342-9802
Practice Address - Street 1:100 CORPORATE CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-1758
Practice Address - Country:US
Practice Address - Phone:717-763-1174
Practice Address - Fax:717-763-8960
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037208E207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA220017922OtherRR MEDICARE
PA0010811750006Medicaid
PA0010811750006Medicaid
PA080253Medicare PIN