Provider Demographics
NPI:1568656155
Name:CLEOFE P EVANGELISTA MD PC
Entity Type:Organization
Organization Name:CLEOFE P EVANGELISTA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CLEOFE
Authorized Official - Middle Name:P
Authorized Official - Last Name:EVANGELISTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-321-0580
Mailing Address - Street 1:301 OXFORD VALLEY RD
Mailing Address - Street 2:SUITE 403A
Mailing Address - City:YARDLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19067-7706
Mailing Address - Country:US
Mailing Address - Phone:215-321-0580
Mailing Address - Fax:215-321-9098
Practice Address - Street 1:301 OXFORD VALLEY RD
Practice Address - Street 2:SUITE 403A
Practice Address - City:YARDLEY
Practice Address - State:PA
Practice Address - Zip Code:19067-7706
Practice Address - Country:US
Practice Address - Phone:215-321-0580
Practice Address - Fax:215-321-9098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030470E207QA0505X
PAMD034070E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB40447Medicare UPIN