Provider Demographics
NPI:1548319817
Name:MADOW, EVAN JARED (DC)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:JARED
Last Name:MADOW
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 BRYAN DAIRY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33777-1437
Mailing Address - Country:US
Mailing Address - Phone:727-548-8100
Mailing Address - Fax:727-548-8112
Practice Address - Street 1:7500 BRYAN DAIRY RD
Practice Address - Street 2:SUITE A
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33777-1437
Practice Address - Country:US
Practice Address - Phone:727-548-8100
Practice Address - Fax:727-548-8112
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0006389111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL44-88108OtherUNITED HEALTHCARE
FL22693OtherBLUE CROSS BLUE SHIELD
FLU22780Medicare UPIN
FL22693Medicare ID - Type Unspecified