Healthcare Provider Details

I. General information

NPI: 1104387950
Provider Name (Legal Business Name): MAGGIE EVISTON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 06/13/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88TH MEDICAL GROUP 4881 SUGAR MAPLE DR
WPAFB OH
45433
US

IV. Provider business mailing address

88TH MEDICAL GROUP 4881 SUGAR MAPLE DR
WPAFB OH
45433
US

V. Phone/Fax

Practice location:
  • Phone: 937-522-2778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0102206425
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0102206425
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number13352563-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: