Provider Demographics
NPI:1477508067
Name:EVANS, JANIE L (OD)
Entity Type:Individual
Prefix:
First Name:JANIE
Middle Name:L
Last Name:EVANS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 NORTHSIDE DR
Mailing Address - Street 2:STE. E
Mailing Address - City:COOL
Mailing Address - State:CA
Mailing Address - Zip Code:95614-9535
Mailing Address - Country:US
Mailing Address - Phone:530-823-5082
Mailing Address - Fax:530-823-5981
Practice Address - Street 1:1020 NORTHSIDE DR
Practice Address - Street 2:STE. E
Practice Address - City:COOL
Practice Address - State:CA
Practice Address - Zip Code:95614-9535
Practice Address - Country:US
Practice Address - Phone:530-823-5082
Practice Address - Fax:530-823-5981
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA 08075T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0080750Medicaid
CA943106565OtherTAX ID
CA943106565OtherTRICARE WEST
CA943106565OtherTAX ID
CASD0080750Medicaid
CA943106565OtherTRICARE WEST