Provider Demographics
NPI:1154800266
Name:EVANS, DAVID EDWARD
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:EDWARD
Last Name:EVANS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19542 FM 2493
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:TX
Mailing Address - Zip Code:75762-8832
Mailing Address - Country:US
Mailing Address - Phone:903-466-4634
Mailing Address - Fax:
Practice Address - Street 1:1401 RICE RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3233
Practice Address - Country:US
Practice Address - Phone:903-561-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2087578225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2087578Medicaid