Provider Demographics
NPI:1730175571
Name:EVANS, ERIC R (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:R
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 1:4189 WESTLAWN S
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1100
Mailing Address - Country:US
Mailing Address - Phone:319-353-5959
Mailing Address - Fax:319-335-7247
Practice Address - Street 1:4189 WESTLAWN S
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1100
Practice Address - Country:US
Practice Address - Phone:319-353-5959
Practice Address - Fax:319-335-7247
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA26811207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA45368OtherWELLMARK BCBS
IA2042697Medicaid
46837OtherMEDICARE PROVIDER NUMBER
IA45368OtherWELLMARK BCBS
IA2042697Medicaid