Provider Demographics
NPI:1528151461
Name:EVANCZYK, BRYAN SAMFORT (MD)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:SAMFORT
Last Name:EVANCZYK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FOX CARE DRIVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:ONEONTA
Mailing Address - State:NY
Mailing Address - Zip Code:13820
Mailing Address - Country:US
Mailing Address - Phone:607-432-3711
Mailing Address - Fax:607-432-6402
Practice Address - Street 1:1 FOX CARE DRIVE
Practice Address - Street 2:SUITE 303
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820
Practice Address - Country:US
Practice Address - Phone:607-432-3711
Practice Address - Fax:607-432-6402
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1620101207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00899665Medicaid
NY00899665Medicaid
NYDD0519Medicare ID - Type Unspecified