Healthcare Provider Details

I. General information

NPI: 1316334899
Provider Name (Legal Business Name): CHARLES EVANS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2015
Last Update Date: 11/27/2023
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 S LAFOUNTAIN ST
KOKOMO IN
46902
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 765-776-3020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number02005711A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: