Provider Demographics
NPI:1922044205
Name:EVANS, GREGORY E (OD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:E
Last Name:EVANS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71956 MAGNESIA FALLS DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-4901
Mailing Address - Country:US
Mailing Address - Phone:760-674-8806
Mailing Address - Fax:760-674-8826
Practice Address - Street 1:71956 MAGNESIA FALLS DR
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4901
Practice Address - Country:US
Practice Address - Phone:760-674-8806
Practice Address - Fax:760-674-8826
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6648TPL152W00000X
CA6648TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6648TPLOtherSTATE LICENSE
CA6648TPLOtherSTATE LICENSE
CA330919946Medicare PIN
SD0066480Medicare PIN