Healthcare Provider Details

I. General information

NPI: 1407952427
Provider Name (Legal Business Name): DAVID GARY EVANS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 S MELROSE DR SUITE 104
VISTA CA
92081-6642
US

IV. Provider business mailing address

1777 KINGS RD
VISTA CA
92084-3640
US

V. Phone/Fax

Practice location:
  • Phone: 760-806-4355
  • Fax: 760-806-4363
Mailing address:
  • Phone: 760-500-1651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberG55686
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: