Provider Demographics
NPI:1043332257
Name:EVANGELISTA, STELLA S (MD)
Entity Type:Individual
Prefix:DR
First Name:STELLA
Middle Name:S
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:STELLA
Other - Middle Name:S
Other - Last Name:EVANGELISTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:10475 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-5704
Mailing Address - Country:US
Mailing Address - Phone:734-427-9440
Mailing Address - Fax:734-427-1701
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?:Yes
Enumeration Date:2007-04-06
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301031561207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101397387Medicaid
MIQ26368012Medicare ID - Type Unspecified
MI101397387Medicaid