Provider Demographics
NPI:1215904180
Name:STATHULIS, EVAN D (MD)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:D
Last Name:STATHULIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 BUCKLES COURT NORTH
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230
Mailing Address - Country:US
Mailing Address - Phone:614-471-9654
Mailing Address - Fax:614-392-4586
Practice Address - Street 1:725 BUCKLES COURT NORTH
Practice Address - Street 2:SUITE 100
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230
Practice Address - Country:US
Practice Address - Phone:614-471-9654
Practice Address - Fax:614-392-4586
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-065900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0122012Medicaid
OH0122012Medicaid
OH4217081Medicare PIN