Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | 22785 | AL |
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 4563 | AL |
NPI | 1093799009 |
---|---|
Provider Name | Dr. Clinton Wilkinson Evans |
First Address | Dothan, AL 36305-6319 |
Second Address | Dothan, AL 36303-1942 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/12/2005 |
Last Update Date | 18/09/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000095652 | (05) | AL |
51095652 | BCBSAL DOTHAN OFFICE (01) | AL |
51097740 | BCBSAL ENTERPRISE OFFICE (01) | AL |
766464 | UNITED CONCORDIA (01) | AL |
H16850 | (02) | AL |