Provider Demographics
NPI:1841215423
Name:ANCHETA, EVANGELINE A (MD)
Entity Type:Individual
Prefix:
First Name:EVANGELINE
Middle Name:A
Last Name:ANCHETA
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 1:609 QUARTER ST
Mailing Address - Street 2:
Mailing Address - City:GLADWIN
Mailing Address - State:MI
Mailing Address - Zip Code:48624-1941
Mailing Address - Country:US
Mailing Address - Phone:989-246-6371
Mailing Address - Fax:989-246-6330
Practice Address - Street 1:609 QUARTER ST
Practice Address - Street 2:
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624-1941
Practice Address - Country:US
Practice Address - Phone:989-246-6371
Practice Address - Fax:989-246-6330
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIEA037604207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0802610352OtherBCBS - PIN
MI4251887Medicaid
MI3374210Medicaid
MIM43020003Medicare PIN
MI4251887Medicaid