Provider Demographics
NPI:1780628107
Name:EVANESCENCE INC
Entity type:Organization
Organization Name:EVANESCENCE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GUSTAVO
Authorized Official - Middle Name:G
Authorized Official - Last Name:LEON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-598-8222
Mailing Address - Street 1:7100 PINES BLVD
Mailing Address - Street 2:SUITE 23
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-7355
Mailing Address - Country:US
Mailing Address - Phone:954-967-0107
Mailing Address - Fax:954-967-0109
Practice Address - Street 1:11760 BIRD ROAD
Practice Address - Street 2:SUITE 710
Practice Address - City:KENDALL
Practice Address - State:FL
Practice Address - Zip Code:33165
Practice Address - Country:US
Practice Address - Phone:305-598-8222
Practice Address - Fax:305-554-0616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 296332086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8956Medicare ID - Type Unspecified