Provider Demographics
NPI:1568479087
Name:EVANS, MARK ALAN (MD,)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:EVANS
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 1:3567 SCIOTO RUN BLVD
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-3013
Mailing Address - Country:US
Mailing Address - Phone:614-876-0563
Mailing Address - Fax:614-876-4678
Practice Address - Street 1:3567 SCIOTO RUN BLVD
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026-3013
Practice Address - Country:US
Practice Address - Phone:614-876-0563
Practice Address - Fax:614-876-4678
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35052367207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0600291Medicaid
OH0600291Medicaid
OHD69043Medicare UPIN