Healthcare Provider Details

I. General information

NPI: 1043231574
Provider Name (Legal Business Name): ED NELVYN LEZETTE EVANS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 PROSPECT AVE BERGEN CBOC-DVA
HACKENSACK NJ
07601-2570
US

IV. Provider business mailing address

1735 VAN CORTLAND TER
TEANECK NJ
07666-6234
US

V. Phone/Fax

Practice location:
  • Phone: 201-342-4536
  • Fax: 201-342-7962
Mailing address:
  • Phone: 201-342-4536
  • Fax: 201-342-7962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: