Healthcare Provider Details

I. General information

NPI: 1205795630
Provider Name (Legal Business Name): MARISTELLA EVANGELISTA, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2026
Last Update Date: 01/21/2026
Certification Date: 01/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36880 WOODWARD AVE STE 203A
BLOOMFIELD HILLS MI
48304-0921
US

IV. Provider business mailing address

1293 SOUTHFIELD RD
BIRMINGHAM MI
48009-3081
US

V. Phone/Fax

Practice location:
  • Phone: 248-329-3571
  • Fax: 248-329-3572
Mailing address:
  • Phone: 248-329-3571
  • Fax: 248-329-3572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: TRAVIS OMMERT
Title or Position: CFO
Credential:
Phone: 419-351-4433