Healthcare Provider Details

I. General information

NPI: 1548766082
Provider Name (Legal Business Name): EVAN MERLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 OAK ST STE 200W
BROCKTON MA
02301-1191
US

IV. Provider business mailing address

830 OAK ST STE 200W
BROCKTON MA
02301-1191
US

V. Phone/Fax

Practice location:
  • Phone: 774-480-1600
  • Fax: 774-480-1625
Mailing address:
  • Phone: 774-480-1600
  • Fax: 774-480-1625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number1016149
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number1016149
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: