Provider Demographics
NPI:1316057391
Name:EVANGELISTA, JOSE L (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:L
Last Name:EVANGELISTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36475 5 MILE RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-1971
Mailing Address - Country:US
Mailing Address - Phone:734-655-1420
Mailing Address - Fax:734-655-1445
Practice Address - Street 1:10475 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-5704
Practice Address - Country:US
Practice Address - Phone:734-427-9440
Practice Address - Fax:734-427-1701
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301031560207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0Q26368OtherGROUP
MI510738OtherCARE CHOICE HMO
MI4199114Medicaid
MI1108214871OtherBLUE CROSS
MI4199114Medicaid
MIQ26368011Medicare ID - Type Unspecified