Provider Demographics
NPI:1578724126
Name:EVANGELIST, MAKENZI COLLEEN (MD)
Entity Type:Individual
Prefix:
First Name:MAKENZI
Middle Name:COLLEEN
Last Name:EVANGELIST
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 1:43 NEW SCOTLAND AVE
Mailing Address - Street 2:MAIL CODE 7
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3412
Mailing Address - Country:US
Mailing Address - Phone:518-262-6696
Mailing Address - Fax:518-262-6770
Practice Address - Street 1:43 NEW SCOTLAND AVE
Practice Address - Street 2:MAIL CODE 7
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3412
Practice Address - Country:US
Practice Address - Phone:518-262-6696
Practice Address - Fax:518-262-6770
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY262155207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03356278Medicaid
NY03356278Medicaid
NYJ400051039Medicare PIN