MEDICARE: DR. PERRY WILLIAM EVANS JR. DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	1856	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942281688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PERRY WILLIAM EVANS JR. DO

Provider Business Mailing Address
First Line	:	119 S BROADWAY ST
Second Line	:
City	:	CLEVELAND
State	:	OK
Zip	:	74020-4614
Country	:	US
Telephone Number	:	918-358-2592
Fax Number	:	918-358-3133

Provider Business Practice Location Address
First Line	:	119 S BROADWAY ST
Second Line	:
City	:	CLEVELAND
State	:	OK
Zip	:	74020-4614
Country	:	US
Telephone Number	:	918-358-2592
Fax Number	:	918-358-3133

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2005
Last Update Date	:	03/09/2010

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