Healthcare Provider Details

I. General information

NPI: 1053930610
Provider Name (Legal Business Name): EVAN JOSEPH KYZAR MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2020
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 RIVERSIDE DR
NEW YORK NY
10032-1007
US

IV. Provider business mailing address

1208 MILLER FARM RD
NATCHITOCHES LA
71457-5326
US

V. Phone/Fax

Practice location:
  • Phone: 646-774-5000
  • Fax:
Mailing address:
  • Phone: 318-471-3824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number311452
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: