Provider Demographics
NPI:1598757197
Name:EVANGELISTA, LUCY Y (MD)
Entity Type:Individual
Prefix:DR
First Name:LUCY
Middle Name:Y
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 1:105 PINE BLUFF RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-7160
Mailing Address - Country:US
Mailing Address - Phone:410-543-2362
Mailing Address - Fax:410-742-0966
Practice Address - Street 1:105 PINE BLUFF RD
Practice Address - Street 2:SUITE 4
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-7160
Practice Address - Country:US
Practice Address - Phone:410-543-2362
Practice Address - Fax:410-742-0966
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0037826208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE25329Medicare UPIN