Provider Demographics
NPI:1104842921
Name:EVANGELISTA, BERNARDO S (MD)
Entity Type:Individual
Prefix:
First Name:BERNARDO
Middle Name:S
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 1:244 ONTARIO ST
Mailing Address - Street 2:
Mailing Address - City:COHOES
Mailing Address - State:NY
Mailing Address - Zip Code:12047-2868
Mailing Address - Country:US
Mailing Address - Phone:518-237-5656
Mailing Address - Fax:
Practice Address - Street 1:244 ONTARIO ST
Practice Address - Street 2:
Practice Address - City:COHOES
Practice Address - State:NY
Practice Address - Zip Code:12047-2868
Practice Address - Country:US
Practice Address - Phone:518-237-5656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY099944174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10000593OtherCDPHP
NY53813Medicare UPIN
NY10000593OtherCDPHP
NY000470554002Medicare UPIN