Provider Demographics
NPI:1033667027
Name:EVARISTO, J ROTSEN (MD)
Entity Type:Individual
Prefix:
First Name:J ROTSEN
Middle Name:
Last Name:EVARISTO
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 1:9415 CAMPUS POINT DR
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92093-1350
Mailing Address - Country:US
Mailing Address - Phone:858-534-2020
Mailing Address - Fax:
Practice Address - Street 1:9415 CAMPUS POINT DR
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093-1350
Practice Address - Country:US
Practice Address - Phone:858-534-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA456390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program