Healthcare Provider Details

I. General information

NPI: 1003019654
Provider Name (Legal Business Name): EVAN SIRC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 10/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1661 SOQUEL DR STE G
SANTA CRUZ CA
95065-1709
US

IV. Provider business mailing address

1661 SOQUEL DR STE G
SANTA CRUZ CA
95065-1709
US

V. Phone/Fax

Practice location:
  • Phone: 831-476-7711
  • Fax:
Mailing address:
  • Phone: 949-263-8620
  • Fax: 800-409-7005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA119825
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: