Healthcare Provider Details

I. General information

NPI: 1669521522
Provider Name (Legal Business Name): CLIFFORD J EVANS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3512 S LAFOUNTAIN ST
KOKOMO IN
46902-3803
US

IV. Provider business mailing address

6626 E 75TH ST SUITE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 765-776-3100
  • Fax: 765-453-8165
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number1985
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberH0070460
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number02003895A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: