Provider Demographics
NPI:1043478779
Name:JOHN R EVANS MD
Entity type:Organization
Organization Name:JOHN R EVANS MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-886-2609
Mailing Address - Street 1:399 E HIGHLAND AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-3808
Mailing Address - Country:US
Mailing Address - Phone:909-886-2609
Mailing Address - Fax:
Practice Address - Street 1:399 E HIGHLAND AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3808
Practice Address - Country:US
Practice Address - Phone:909-886-2609
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0051140Medicaid