Provider Demographics
NPI:1952358889
Name:EVANS, JOHN EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
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 1:901 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-1417
Mailing Address - Country:US
Mailing Address - Phone:270-259-5641
Mailing Address - Fax:270-259-5309
Practice Address - Street 1:901 WALLACE AVE
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-1417
Practice Address - Country:US
Practice Address - Phone:270-259-5641
Practice Address - Fax:270-259-5309
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38545208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64082829Medicaid
KY0664805Medicare ID - Type UnspecifiedMEDICARE
KY64082829Medicaid