Provider Demographics
NPI:1730172776
Name:EVANS, STEPHEN J (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:EVANS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:50 LAKEFRONT BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-4345
Mailing Address - Country:US
Mailing Address - Phone:716-849-8750
Mailing Address - Fax:716-849-8757
Practice Address - Street 1:50 LAKEFRONT BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-4345
Practice Address - Country:US
Practice Address - Phone:716-849-8750
Practice Address - Fax:716-849-8757
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2013-11-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY177137207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01173293Medicaid
C66142Medicare UPIN
NY01173293Medicaid