Provider Demographics
NPI:1922002302
Name:EVANGELISTA, ANTHONY WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:WILLIAM
Last Name:EVANGELISTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3900 E MEXICO AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-3941
Mailing Address - Country:US
Mailing Address - Phone:720-524-1001
Mailing Address - Fax:720-524-1121
Practice Address - Street 1:350 E INTERSTATE 20
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76018-1119
Practice Address - Country:US
Practice Address - Phone:817-784-0222
Practice Address - Fax:817-467-5819
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2020-04-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXK0028207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP088X3726Medicaid
TX88X372Medicare ID - Type Unspecified
TXP088X3726Medicaid