Provider Demographics
NPI:1932154077
Name:EVANS, RICHARD N JR (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:N
Last Name:EVANS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1001 W GLEN OAKS LN
Mailing Address - Street 2:STE 105
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3369
Mailing Address - Country:US
Mailing Address - Phone:414-365-3210
Mailing Address - Fax:414-365-3225
Practice Address - Street 1:2266 N PROSPECT AVE
Practice Address - Street 2:#518
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-6319
Practice Address - Country:US
Practice Address - Phone:414-277-7733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25926208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30588200Medicaid
WI000001814Medicare PIN
WI000901666Medicare PIN
E22317Medicare UPIN