Provider Demographics
NPI:1134469208
Name:EVANGELISTA, JOHN (DPT)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:EVANGELISTA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 FELLOWSHIP RD STE 290
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-3418
Mailing Address - Country:US
Mailing Address - Phone:856-424-5552
Mailing Address - Fax:856-424-5559
Practice Address - Street 1:523 FELLOWSHIP RD STE 290
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-3418
Practice Address - Country:US
Practice Address - Phone:856-424-5552
Practice Address - Fax:856-424-5559
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-26
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01477000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist