Healthcare Provider Details

I. General information

NPI: 1710737366
Provider Name (Legal Business Name): EVANS KIRKWOOD LODGE MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2024
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 N MICHIGAN ST
SOUTH BEND IN
46601-1035
US

IV. Provider business mailing address

714 N MICHIGAN ST
SOUTH BEND IN
46601-1035
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-7477
  • Fax:
Mailing address:
  • Phone: 574-647-7477
  • Fax: 574-647-6819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01097297A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: