Provider Demographics
NPI:1366427429
Name:PROVISOR, EVAN PAUL (MD)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:PAUL
Last Name:PROVISOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-4000
Mailing Address - Country:US
Mailing Address - Phone:508-764-6966
Mailing Address - Fax:508-764-2457
Practice Address - Street 1:94 SOUTH ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-4000
Practice Address - Country:US
Practice Address - Phone:508-764-6966
Practice Address - Fax:508-764-2457
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA237945208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2160307Medicaid
MA2160307Medicaid
B37903Medicare UPIN
MA000741601Medicare PIN