Provider Demographics
NPI:1083664262
Name:EVANGELISTA, BAYANI V (MD)
Entity Type:Individual
Prefix:
First Name:BAYANI
Middle Name:V
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:PO BOX 910329
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92191-0329
Mailing Address - Country:US
Mailing Address - Phone:858-564-1400
Mailing Address - Fax:858-564-1500
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:EISENHOWER IMAGING CENTER
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-340-3911
Practice Address - Fax:760-674-3852
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA859852085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A859850OtherBLUE SHIELD OF CA
CA00A859850Medicaid
CAP00224881Medicare PIN
H98804Medicare UPIN
CA00A859850Medicare PIN