Healthcare Provider Details

I. General information

NPI: 1649614108
Provider Name (Legal Business Name): PERRY JAYMES EVANGELISTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2013
Last Update Date: 01/01/2020
Certification Date: 01/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3271 N CIVIC CENTER PLZ STE 110
SCOTTSDALE AZ
85251-6990
US

IV. Provider business mailing address

PO BOX 5495
SCOTTSDALE AZ
85261-5495
US

V. Phone/Fax

Practice location:
  • Phone: 480-656-0291
  • Fax: 480-656-0127
Mailing address:
  • Phone: 480-656-0291
  • Fax: 480-656-0127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number56465
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number56465
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: