Provider Demographics
NPI:1699749127
Name:EVANS, EVAN M (MD)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:M
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:PO BOX 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-531-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH62012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000527435OtherBS KY PROVIDER #
TX103066009Medicaid
TX752616977007OtherTRICARE TRINITY CLINIC
TX8CU198OtherBCBS MFH-JV-RBC LOCATION
KY7100015000Medicaid
TX103066004Medicaid
TXTIN PLUS 005OtherTRICARE MFH-JV-RBC LOCATION
TX103066008Medicaid
TX750818167013OtherTRICARE MFH/ROSS BREAST CENTER
TX8B0529OtherBCBS MFH/ROSS BREAST CENTER
TX8M8275OtherBCBS TRINITY CLINIC
TX752616977113OtherTRICARE
TX752616977113OtherTRICARE
TXTXB114799Medicare Oscar/Certification
TX8M8275OtherBCBS TRINITY CLINIC
TX8CU198OtherBCBS MFH-JV-RBC LOCATION
TXTXB114940Medicare Oscar/Certification
KY00280004Medicare PIN
TXTIN PLUS 005OtherTRICARE MFH-JV-RBC LOCATION
KY7100015000Medicaid
TX103066009Medicaid
TX103066008Medicaid
KY0903695Medicare PIN