Healthcare Provider Details

I. General information

NPI: 1053147769
Provider Name (Legal Business Name): MITCHELL N EVANS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 09/10/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10564 N MAIN ST STE E
ARCHDALE NC
27263-2483
US

IV. Provider business mailing address

PO BOX 4370
ARCHDALE NC
27263-4370
US

V. Phone/Fax

Practice location:
  • Phone: 336-434-4033
  • Fax: 336-434-4035
Mailing address:
  • Phone: 336-687-7730
  • Fax: 336-434-6680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2809
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: