Provider Demographics
NPI:1417964578
Name:EVANGELISTA, FLOR VELASCO (MD)
Entity Type:Individual
Prefix:
First Name:FLOR
Middle Name:VELASCO
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 HOLLIS ST
Mailing Address - Street 2:
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443-3730
Mailing Address - Country:US
Mailing Address - Phone:309-852-5604
Mailing Address - Fax:309-852-3865
Practice Address - Street 1:615 HOLLIS ST
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-3730
Practice Address - Country:US
Practice Address - Phone:309-852-5604
Practice Address - Fax:309-852-3865
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
D09796Medicare UPIN
213350Medicare ID - Type Unspecified