Provider Demographics
NPI:1801971148
Name:EVENSEN, MARC EIVIND (MD)
Entity type:Individual
Prefix:
First Name:MARC EIVIND
Middle Name:
Last Name:EVENSEN
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 1:5901 E 7TH ST
Mailing Address - Street 2:PO BOX 54779
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90822-5201
Mailing Address - Country:US
Mailing Address - Phone:714-456-6369
Mailing Address - Fax:
Practice Address - Street 1:UCI MEDICAL CENTER
Practice Address - Street 2:101 THE CITY DRIVE SOUTH
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868
Practice Address - Country:US
Practice Address - Phone:714-456-8978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA000000A65848208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA65848AMedicare PIN