Healthcare Provider Details

I. General information

NPI: 1821431560
Provider Name (Legal Business Name): MATT EVANS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MATTHEW DOUGLAS EVANS MD

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 S 1ST AVE
PHOENIX AZ
85003-2692
US

IV. Provider business mailing address

3060 N RIDGECREST UNIT 161
MESA AZ
85207-1081
US

V. Phone/Fax

Practice location:
  • Phone: 602-258-6797
  • Fax:
Mailing address:
  • Phone: 480-332-9227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number54817
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number54817
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: