Provider Demographics
NPI:1063417863
Name:EVANS, DAVID G (OD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:G
Last Name:EVANS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6060 PRIMACY PKWY
Mailing Address - Street 2:STE 200
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5770
Mailing Address - Country:US
Mailing Address - Phone:901-761-4620
Mailing Address - Fax:907-761-3072
Practice Address - Street 1:6060 PRIMACY PKWY
Practice Address - Street 2:STE 200
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5770
Practice Address - Country:US
Practice Address - Phone:901-761-4620
Practice Address - Fax:907-761-3072
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2008-02-20
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
TNODT1596152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3599522Medicaid
TNU53108Medicare UPIN
TN3599522Medicare ID - Type UnspecifiedTENNESSEE MEDICARE