Healthcare Provider Details

I. General information

NPI: 1326335902
Provider Name (Legal Business Name): CHARLES E. EVANS III D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2011
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 LAKELAND DR STE 1052
JACKSON MS
39216-4609
US

IV. Provider business mailing address

971 LAKELAND DR STE 1052
JACKSON MS
39216-4609
US

V. Phone/Fax

Practice location:
  • Phone: 601-981-9503
  • Fax: 601-981-7895
Mailing address:
  • Phone: 601-981-9503
  • Fax: 601-981-7895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number22904
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: