Healthcare Provider Details

I. General information

NPI: 1245556455
Provider Name (Legal Business Name): STEPHANIE EVANSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2010
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10020 DONALD S POWERS DR STE 2A
MUNSTER IN
46321-4054
US

IV. Provider business mailing address

8558 BROADWAY
MERRILLVILLE IN
46410-7032
US

V. Phone/Fax

Practice location:
  • Phone: 219-703-2427
  • Fax: 219-703-6961
Mailing address:
  • Phone: 219-392-7084
  • Fax: 219-703-6854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number62305
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01081251A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: