=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497287734
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVIN LAKE GUILLIAMS D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2017
-----------------------------------------------------
Last Update Date | 05/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 617 23RD ST STE 106
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41101-2880
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-329-1770
-----------------------------------------------------
Fax | 606-329-1768
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 746647
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30374-6647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-388-6518
-----------------------------------------------------
Fax | 904-384-1005
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207T00000X
-----------------------------------------------------
Taxonomy Name | Neurological Surgery Physician
-----------------------------------------------------
License Number | OS21210
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207T00000X
-----------------------------------------------------
Taxonomy Name | Neurological Surgery Physician
-----------------------------------------------------
License Number | TP273
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------