1235495011 NPI number — JESSICA MARIE EVANS MD

Table of content: JESSICA MARIE EVANS MD (NPI 1235495011)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235495011 NPI number — JESSICA MARIE EVANS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
JESSICA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RANDO
Provider Other First Name:
JESSICA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235495011
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3131 NEWMARK DR STE 220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMISBURG
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45342-5400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-438-8910
Provider Business Mailing Address Fax Number:
937-436-4984

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3535 SOUTHERN BLVD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KETTERING
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45429-1221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-395-8166
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/06/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 35.122407 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0096394 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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