Healthcare Provider Details

I. General information

NPI: 1922044205
Provider Name (Legal Business Name): GREGORY E EVANS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 04/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71956 MAGNESIA FALLS DR
RANCHO MIRAGE CA
92270-4901
US

IV. Provider business mailing address

71956 MAGNESIA FALLS DR
RANCHO MIRAGE CA
92270-4901
US

V. Phone/Fax

Practice location:
  • Phone: 760-674-8806
  • Fax: 760-674-8826
Mailing address:
  • Phone: 760-674-8806
  • Fax: 760-674-8826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6648TPL
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6648TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: