Provider Demographics
NPI:1013362482
Name:EVANS, MARK GORDON (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:GORDON
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 1:1986 E FARM CIR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-6296
Mailing Address - Country:US
Mailing Address - Phone:801-891-6469
Mailing Address - Fax:801-944-3813
Practice Address - Street 1:101 THE CITY DR S
Practice Address - Street 2:BLDG. 1, RM. 3622, ZOT 4805
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3201
Practice Address - Country:US
Practice Address - Phone:714-456-6411
Practice Address - Fax:949-824-2160
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program