Provider Demographics
NPI:1598087033
Name:ROBERT L EVANS OD &MARILYN A CARTER OD A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:ROBERT L EVANS OD &MARILYN A CARTER OD A PROFESSIONAL CORP
Other - Org Name:ROBERT L EVANS OD & MARILYN A CARTER OD A PROFESSIONAL CORP.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:EVANS. OD.
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:619-422-5361
Mailing Address - Street 1:510 S MAGNOLIA AVE
Mailing Address - Street 2:DR ROBERT L. EVANS. MARILYN A. CARTER OD.
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-6011
Mailing Address - Country:US
Mailing Address - Phone:619-444-9012
Mailing Address - Fax:619-444-0232
Practice Address - Street 1:330 OXFORD ST
Practice Address - Street 2:SUITE 206
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-3117
Practice Address - Country:US
Practice Address - Phone:619-422-5361
Practice Address - Fax:619-422-7021
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROBERT L EVANS OD & MARILYN A CARTER OD A PROFESSIONAL CORP.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-25
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT4790 TPA152W00000X
CAOP4834152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1861461972Medicaid
CA1861461972Medicaid
CA0795700001Medicare PIN