Healthcare Provider Details

I. General information

NPI: 1932194644
Provider Name (Legal Business Name): CHARLES DAVID EVANCHO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 07/23/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CORPORATE CENTER DR STE 100
CAMP HILL PA
17011-1758
US

IV. Provider business mailing address

PO BOX 750
SCRANTON PA
18501-0750
US

V. Phone/Fax

Practice location:
  • Phone: 717-763-1174
  • Fax: 717-763-8960
Mailing address:
  • Phone: 570-346-7797
  • Fax: 570-342-9802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberMD037208E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: