Provider Demographics
NPI:1871591768
Name:EVANS, DOUGLAS EUGENE (DO)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:EUGENE
Last Name:EVANS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 N 36TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2977
Mailing Address - Country:US
Mailing Address - Phone:816-271-4022
Mailing Address - Fax:816-271-4020
Practice Address - Street 1:711 N 36TH ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2977
Practice Address - Country:US
Practice Address - Phone:816-271-4022
Practice Address - Fax:816-271-4020
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110143208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
E78875Medicare UPIN