Provider Demographics
NPI:1174696140
Name:EVANS, KERRY L (MD)
Entity type:Individual
Prefix:DR
First Name:KERRY
Middle Name:L
Last Name:EVANS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1922 FM 256 W
Mailing Address - Street 2:
Mailing Address - City:WOODVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75979-2333
Mailing Address - Country:US
Mailing Address - Phone:409-837-9012
Mailing Address - Fax:
Practice Address - Street 1:1922 FM 256 W
Practice Address - Street 2:
Practice Address - City:WOODVILLE
Practice Address - State:TX
Practice Address - Zip Code:75979-2333
Practice Address - Country:US
Practice Address - Phone:409-837-9012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5922207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX44894608Medicaid
TX44894608Medicaid