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General NPI Number Information
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NPI Number | 1851394175
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Entity Type | Individual
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Provider Name | VAN EVANOFF JR. M.D.
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Gender | Male
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Dates
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Enumeration Date | 05/31/2005
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Last Update Date | 05/25/2016
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Provider Practice Location Address
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Address Line | 2204 N SECTION ST SUITE B
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City | SULLIVAN
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State | IN
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Zip | 47882-0010
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Country | US
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Telephone | 812-268-2556
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Fax | 812-268-2652
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Provider Business Mailing Address
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Address Line | 2204 N SECTION ST PO BOX 10 SUITE B
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City | SULLIVAN
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State | IN
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Zip | 47882-0010
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Country | US
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Telephone | 812-268-2556
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Fax | 812-268-2652
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number | 01053652A
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License Number State | IN
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