Provider Demographics
NPI:1427275858
Name:CHARLES A EVANS MD PA
Entity type:Organization
Organization Name:CHARLES A EVANS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-699-5433
Mailing Address - Street 1:203 CHRISTIE STREET
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904
Mailing Address - Country:US
Mailing Address - Phone:936-699-5433
Mailing Address - Fax:936-699-5465
Practice Address - Street 1:203 CHRISTIE STREET
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904
Practice Address - Country:US
Practice Address - Phone:936-699-5433
Practice Address - Fax:936-699-5465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3094207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXJ3094OtherSTATE MEDICAL LICENSE #
TX123490806Medicaid
TX0066MTOtherBCBS PROV#
TX179637701Medicaid
TXP00310208Medicare ID - Type UnspecifiedRR MCARE INDIV PROV#
TXDE7007Medicare ID - Type UnspecifiedRR MCARE GROUP ID#
TX00W502Medicare ID - Type UnspecifiedMCARE GROUP#
TX8F2949Medicare ID - Type UnspecifiedMCARE INDIVIDUAL PROV#
TX179637701Medicaid