Provider Demographics
NPI:1649405283
Name:EGAN, ETHAN A (MD)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:A
Last Name:EGAN
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 1:5630 E SANTA ANA CANYON RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-3122
Mailing Address - Country:US
Mailing Address - Phone:714-804-1000
Mailing Address - Fax:
Practice Address - Street 1:5630 E SANTA ANA CANYON RD
Practice Address - Street 2:SUITE 150
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-3122
Practice Address - Country:US
Practice Address - Phone:714-804-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-27
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA134845208100000X, 2081S0010X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine