=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205368784
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVAN BARRY FLETCHER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2017
-----------------------------------------------------
Last Update Date | 04/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 RIVERS EDGE RD
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10035-1163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-766-3810
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 81A OCEAN AVE
-----------------------------------------------------
City | MASSAPEQUA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11758-7971
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-678-8936
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084F0202X
-----------------------------------------------------
Taxonomy Name | Forensic Psychiatry Physician
-----------------------------------------------------
License Number | 315587-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------