Healthcare Provider Details

I. General information

NPI: 1609480201
Provider Name (Legal Business Name): EVAN FORD DRAPER AUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2020
Last Update Date: 05/17/2022
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1842 BEACON ST STE 403
BROOKLINE MA
02445-1930
US

IV. Provider business mailing address

1842 BEACON ST STE 403
BROOKLINE MA
02445-1930
US

V. Phone/Fax

Practice location:
  • Phone: 617-232-1299
  • Fax: 617-232-7959
Mailing address:
  • Phone: 617-232-1299
  • Fax: 617-232-7959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberA798
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: