Healthcare Provider Details

I. General information

NPI: 1013952886
Provider Name (Legal Business Name): EVANS PEDIATRIC CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3912 SHERMAN AVE
SAINT JOSEPH MO
64506-3648
US

IV. Provider business mailing address

3912 SHERMAN AVE
SAINT JOSEPH MO
64506-3648
US

V. Phone/Fax

Practice location:
  • Phone: 816-233-5959
  • Fax: 816-233-5960
Mailing address:
  • Phone: 816-233-5959
  • Fax: 816-233-5960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number110143
License Number StateMO

VIII. Authorized Official

Name: DR. DOUGLAS EUGENE EVANS
Title or Position: OWNER
Credential: D.O.
Phone: 816-351-6385