Healthcare Provider Details

I. General information

NPI: 1538237797
Provider Name (Legal Business Name): EVELYN RIDENHOUR CALLAS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 PINE ST
MOUNT SHASTA CA
96067-2143
US

IV. Provider business mailing address

917 ROCKFELLOW DRIVE
MOUNT SHASTA CA
96067-3904
US

V. Phone/Fax

Practice location:
  • Phone: 530-926-5105
  • Fax:
Mailing address:
  • Phone: 530-926-0906
  • Fax: 530-926-0906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA16901
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: