Provider Demographics
NPI:1437293446
Name:EVANS, EDWARD BARTON (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:BARTON
Last Name:EVANS
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 1:161 THUNDER DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6016
Mailing Address - Country:US
Mailing Address - Phone:760-941-6664
Mailing Address - Fax:760-941-3257
Practice Address - Street 1:161 THUNDER DR
Practice Address - Street 2:SUITE 104
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6016
Practice Address - Country:US
Practice Address - Phone:760-941-6664
Practice Address - Fax:760-941-3257
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43785207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G437850Medicaid
CAA92441Medicare UPIN
CAWG43785CMedicare ID - Type Unspecified