Provider Demographics
NPI:1013370865
Name:RUSOJA, EVAN ANDREW (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:ANDREW
Last Name:RUSOJA
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:EVAN
Other - Middle Name:ANDREW
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1411 E 31ST ST
Mailing Address - Street 2:QIC 2212
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-1018
Mailing Address - Country:US
Mailing Address - Phone:510-437-4564
Mailing Address - Fax:
Practice Address - Street 1:1411 E 31ST ST
Practice Address - Street 2:QIC 2212
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-1018
Practice Address - Country:US
Practice Address - Phone:510-437-4564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA155678207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program