Provider Demographics
NPI:1932158862
Name:EVANGELISTA, LILIA A (MD)
Entity Type:Individual
Prefix:DR
First Name:LILIA
Middle Name:A
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 HAWKINS ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10464-1415
Mailing Address - Country:US
Mailing Address - Phone:718-885-1915
Mailing Address - Fax:718-885-9221
Practice Address - Street 1:26 HAWKINS ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10464-1415
Practice Address - Country:US
Practice Address - Phone:718-885-1915
Practice Address - Fax:718-885-9221
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY123772208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01009269Medicaid
NYG-51241Medicare UPIN
NY01009269Medicaid