Provider Demographics
NPI:1366434110
Name:EVERS, MARTIN L (MD)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:L
Last Name:EVERS
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 1:161 E MAIN ST
Mailing Address - Street 2:STE 300-301
Mailing Address - City:PORT JERVIS
Mailing Address - State:NY
Mailing Address - Zip Code:12771-2113
Mailing Address - Country:US
Mailing Address - Phone:845-856-3284
Mailing Address - Fax:
Practice Address - Street 1:104 BENNETT AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:PA
Practice Address - Zip Code:18337-9759
Practice Address - Country:US
Practice Address - Phone:570-409-0321
Practice Address - Fax:570-409-8642
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042947207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001189983 0007Medicaid
NY2139499Medicaid
E44391Medicare UPIN
PA578378QLQMedicare ID - Type Unspecified
NY2139499Medicaid