Provider Demographics
NPI:1528626140
Name:UNDERWOOD, EVAN ROBERT (DPT)
Entity type:Individual
Prefix:MR
First Name:EVAN
Middle Name:ROBERT
Last Name:UNDERWOOD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10415 REDFIELD LN
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:MO
Mailing Address - Zip Code:65032
Mailing Address - Country:US
Mailing Address - Phone:573-380-1785
Mailing Address - Fax:
Practice Address - Street 1:1930 N BUSINESS ROUTE 5 UNIT 1B
Practice Address - Street 2:
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020-2659
Practice Address - Country:US
Practice Address - Phone:573-346-7445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019016835225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist