Provider Demographics
NPI:1699770677
Name:EVANS, JUDSON HOLT II (MD)
Entity type:Individual
Prefix:
First Name:JUDSON
Middle Name:HOLT
Last Name:EVANS
Suffix:II
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 3686
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28406-0686
Mailing Address - Country:US
Mailing Address - Phone:910-442-1100
Mailing Address - Fax:910-442-1199
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7407
Practice Address - Country:US
Practice Address - Phone:910-442-1100
Practice Address - Fax:910-442-1199
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34307207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00852717OtherMEDICARE RAILRAOD
NC2162106GOtherMEDICARE PTAN
NC893094BMedicaid
NC2162106EOtherMEDICARE PTAN
NC893094BMedicaid
2162106Medicare ID - Type Unspecified
NC1992708747Medicare PIN