Healthcare Provider Details

I. General information

NPI: 1366625212
Provider Name (Legal Business Name): KAREN BACON EVANS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2007
Last Update Date: 10/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6735 CONROY WINDERMERE RD STE 314
ORLANDO FL
32835-3565
US

IV. Provider business mailing address

1307 N LAKE HOWARD DR
WINTER HAVEN FL
33881-3127
US

V. Phone/Fax

Practice location:
  • Phone: 407-203-0936
  • Fax:
Mailing address:
  • Phone: 407-203-0936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME99690
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME99690
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: