1598087033 NPI number — ROBERT L EVANS OD &MARILYN A CARTER OD A PROFESSIONAL CORP

Table of content: (NPI 1598087033)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598087033 NPI number — ROBERT L EVANS OD &MARILYN A CARTER OD A PROFESSIONAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBERT L EVANS OD &MARILYN A CARTER OD A PROFESSIONAL CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598087033
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
510 S MAGNOLIA AVE
Provider Second Line Business Mailing Address:
DR ROBERT L. EVANS. MARILYN A. CARTER OD.
Provider Business Mailing Address City Name:
EL CAJON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92020-6011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-444-9012
Provider Business Mailing Address Fax Number:
619-444-0232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 OXFORD ST
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91911-3117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-422-5361
Provider Business Practice Location Address Fax Number:
619-422-7021
Provider Enumeration Date:
02/25/2010

Additional Information

Authorized Official

Authorized Official Last Name:
EVANS. OD.
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
619-422-5361

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OP4834 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: OPT4790 TPA , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1861461972 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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