Provider Demographics
NPI:1952350050
Name:EVANS, STEPHEN DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:DOUGLAS
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 1:1112 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5010
Mailing Address - Country:US
Mailing Address - Phone:575-627-4200
Mailing Address - Fax:575-627-4212
Practice Address - Street 1:1112 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5010
Practice Address - Country:US
Practice Address - Phone:575-627-4200
Practice Address - Fax:575-627-4212
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM86-226207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00039479Medicaid
NMD35613Medicare UPIN
NM00039479Medicaid