Provider Demographics
NPI:1548249238
Name:EVANS, JEFFRY T (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFRY
Middle Name:T
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 1:100 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-6877
Mailing Address - Country:US
Mailing Address - Phone:573-231-3139
Mailing Address - Fax:573-231-3711
Practice Address - Street 1:100 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6877
Practice Address - Country:US
Practice Address - Phone:573-231-3139
Practice Address - Fax:573-231-3711
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2021-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112304207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208903609Medicaid
G10782Medicare UPIN
MO007013772Medicare ID - Type Unspecified