Provider Demographics
NPI:1932152352
Name:EVANGELISTA, VINCENT (DPM)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:
Last Name:EVANGELISTA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004384213ES0103X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1120236Medicaid
NYT51500Medicare UPIN
NY21654Medicare ID - Type UnspecifiedMEDICARE GHI PROVIDER ID