Provider Demographics
NPI:1841591955
Name:DR. VINCENT EVANGELISTA, DPM PC
Entity Type:Organization
Organization Name:DR. VINCENT EVANGELISTA, DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANGELISTA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:718-848-5700
Mailing Address - Street 1:9715 101ST AVE
Mailing Address - Street 2:
Mailing Address - City:OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11416-2523
Mailing Address - Country:US
Mailing Address - Phone:718-848-5700
Mailing Address - Fax:718-323-0449
Practice Address - Street 1:9715 101ST AVE
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11416-2523
Practice Address - Country:US
Practice Address - Phone:718-848-5700
Practice Address - Fax:718-323-0449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004384213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01120236Medicaid
NY21654Medicare PIN
NY01120236Medicaid