Provider Demographics
NPI:1497180608
Name:EVANS, DAVID (DPT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3639 MIDWAY DR STE B286
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5254
Mailing Address - Country:US
Mailing Address - Phone:858-488-3597
Mailing Address - Fax:858-724-1747
Practice Address - Street 1:2999 MISSION BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-8028
Practice Address - Country:US
Practice Address - Phone:858-488-3597
Practice Address - Fax:858-724-1747
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40297225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17206Medicare UPIN