Healthcare Provider Details

I. General information

NPI: 1760892483
Provider Name (Legal Business Name): GREGORY T EVANGELISTA MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2014
Last Update Date: 09/02/2019
Certification Date:
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 Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: GREGORY T EVANGELISTA
Title or Position: PHYSICIAN OWNER
Credential: M.D.
Phone: 480-254-8482