Basic Information
| Provider Information | |||||||||
| NPI: | 1316043177 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EVELYN AND FLICKINGER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17136 PATINA ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921275700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586761926 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4077 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921032105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192607022 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FLICKINGER | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | DEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8586761926 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00G478590 | 05 | CA | MEDICAID |