Healthcare Provider Details

I. General information

NPI: 1104865831
Provider Name (Legal Business Name): EVAN C JONES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 STONY BROOK RD STE 200
STONY BROOK NY
11790-2215
US

IV. Provider business mailing address

PO BOX 1559
STONY BROOK NY
11790-0989
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-4272
  • Fax:
Mailing address:
  • Phone: 631-444-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number235279
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: