Provider Demographics
NPI:1063676807
Name:EVERTON, MICHAEL JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:EVERTON
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 1:4094 4TH AVE
Mailing Address - Street 2:SUITE 200, MC 0834
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2143
Mailing Address - Country:US
Mailing Address - Phone:312-282-2638
Mailing Address - Fax:
Practice Address - Street 1:4094 4TH AVE
Practice Address - Street 2:SUITE 200, MC 0834
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2143
Practice Address - Country:US
Practice Address - Phone:312-282-2638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125054416207R00000X
CAA1240402085R0202X
TXR77272085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine