Provider Demographics
NPI:1164491031
Name:EVANGELISTA, GREGORY THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:THOMAS
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 5495
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85261-5495
Mailing Address - Country:US
Mailing Address - Phone:480-656-0291
Mailing Address - Fax:480-656-4570
Practice Address - Street 1:3271 N CIVIC CENTER PLZ STE 110
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-6990
Practice Address - Country:US
Practice Address - Phone:480-656-0291
Practice Address - Fax:480-656-0127
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2020-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34837207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ113429Medicaid
AZ114049Medicare PIN
AZ113429Medicaid