Provider Demographics
NPI:1326092107
Name:EVANGELISTI, STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:EVANGELISTI
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 1:1901 LAC DE VILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-5627
Mailing Address - Country:US
Mailing Address - Phone:585-325-1120
Mailing Address - Fax:585-423-0471
Practice Address - Street 1:1901 LAC DE VILLE BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-5627
Practice Address - Country:US
Practice Address - Phone:585-325-1120
Practice Address - Fax:585-423-0471
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173597-1208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01669589Medicaid
NY14554BMedicare ID - Type UnspecifiedMEDICARE PROVIDER #
NY01669589Medicaid