Provider Demographics
NPI:1508854472
Name:EVANGELISTA, PETER THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:PETER
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 1:125 METRO CENTER BLVD STE 2000
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-1785
Mailing Address - Country:US
Mailing Address - Phone:401-432-2520
Mailing Address - Fax:401-453-8220
Practice Address - Street 1:125 METRO CENTER BLVD STE 2000
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-1785
Practice Address - Country:US
Practice Address - Phone:401-432-2520
Practice Address - Fax:401-453-8220
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD114082085R0202X
MA2170242085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
003124047OtherCT MED ASSISTANCE
2465834OtherCIGNA
9356928OtherPHHCS
2081920OtherMASSMEDICAID
3707988OtherAETNA
AA16956OtherRIHPILGRIM
P00120864OtherRAILROAD MEDICARE
411628OtherBLUECHIP
9003434OtherRIMEDICALASSISTANCE