=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366184590
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVAN CHARLES DEFALCO DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2022
-----------------------------------------------------
Last Update Date | 10/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 447 W MAIN ST
-----------------------------------------------------
City | MONONGAHELA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15063-2564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-258-2070
-----------------------------------------------------
Fax | 724-258-3582
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 HOSPITAL AVE
-----------------------------------------------------
City | DU BOIS
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15801-1440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-375-2200
-----------------------------------------------------
Fax | 814-375-2484
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS024993
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------