Provider Demographics
NPI:1629018619
Name:EVANGELISTA, ADELBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:ADELBERT
Middle Name:
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:PO BOX 5147
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85366-2458
Mailing Address - Country:US
Mailing Address - Phone:928-726-6772
Mailing Address - Fax:
Practice Address - Street 1:2281 W 24TH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6154
Practice Address - Country:US
Practice Address - Phone:928-726-6772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2018-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42221207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2706708385OtherEIN