Provider Demographics
NPI:1750609285
Name:WALGAMA, EVAN (MD)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:
Last Name:WALGAMA
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 1:4140 W 190TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8635 W 3RD ST STE 590W
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-6163
Practice Address - Country:US
Practice Address - Phone:310-423-1220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-07
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1368192086X0206X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX413495902OtherMEDICAID-CSHCN
TX413495901Medicaid
TX8NB125OtherBCBS