Provider Demographics
NPI:1871583674
Name:EVANGELISTA, MARIA V (MD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:V
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:211 N EDDY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2808
Mailing Address - Country:US
Mailing Address - Phone:574-237-9261
Mailing Address - Fax:574-237-9208
Practice Address - Street 1:211 N EDDY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2808
Practice Address - Country:US
Practice Address - Phone:574-237-9261
Practice Address - Fax:574-237-9208
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01048781A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200191780Medicaid
IN146470LLMedicare ID - Type Unspecified
IN200191780Medicaid