Provider Demographics
NPI:1407952427
Name:EVANS, DAVID GARY (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:GARY
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 1:1777 KINGS RD
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-3640
Mailing Address - Country:US
Mailing Address - Phone:760-500-1651
Mailing Address - Fax:
Practice Address - Street 1:410 S MELROSE DR
Practice Address - Street 2:SUITE 104
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-6642
Practice Address - Country:US
Practice Address - Phone:760-806-4355
Practice Address - Fax:760-806-4363
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55686207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE93248Medicare UPIN