Provider Demographics
NPI:1134336159
Name:LIVONIA DIAGNOSTIC CENTER,P.C.
Entity type:Organization
Organization Name:LIVONIA DIAGNOSTIC CENTER,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:L
Authorized Official - Last Name:EVANGELISTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-427-9440
Mailing Address - Street 1:10475 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-5704
Mailing Address - Country:US
Mailing Address - Phone:734-427-9440
Mailing Address - Fax:734-427-1701
Practice Address - Street 1:10475 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-5704
Practice Address - Country:US
Practice Address - Phone:734-427-9440
Practice Address - Fax:734-427-1701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301031560173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty