Provider Demographics
NPI:1992746598
Name:EVANS, VIRGINIA ANN (MD)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:ANN
Last Name:EVANS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16500 KENNETH LN
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-1132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14519 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4316
Practice Address - Country:US
Practice Address - Phone:216-521-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35041617E207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH930022100OtherMEDICARE TRAVELERS RR-GA
OH0404744Medicaid
OH942460636259OtherCARESOURCE
OH942460636259OtherCARESOURCE
OH0404744Medicaid