Healthcare Provider Details

I. General information

NPI: 1962720821
Provider Name (Legal Business Name): MARISTELLA S EVANGELISTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2010
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

1293 SOUTHFIELD RD
BIRMINGHAM MI
48009-3081
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2378
  • Fax:
Mailing address:
  • Phone: 734-945-7295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number35127325
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberA112635
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number4301116571
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: