Provider Demographics
NPI:1134285091
Name:RANSOM, EVAN ROGERS (MD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:ROGERS
Last Name:RANSOM
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 1:1000 S ELISEO DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2133
Mailing Address - Country:US
Mailing Address - Phone:215-469-0927
Mailing Address - Fax:
Practice Address - Street 1:1000 S ELISEO DR
Practice Address - Street 2:SUITE 103
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2133
Practice Address - Country:US
Practice Address - Phone:215-469-0927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA117324207YX0905X
NY259357207YX0905X
PAMD437508207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFW557AOtherMEDICARE PTAN
A300045054OtherMEDICARE PTAN