Healthcare Provider Details

I. General information

NPI: 1316057391
Provider Name (Legal Business Name): JOSE L. EVANGELISTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10475 FARMINGTON RD
LIVONIA MI
48150-5704
US

IV. Provider business mailing address

36475 5 MILE RD
LIVONIA MI
48154-1971
US

V. Phone/Fax

Practice location:
  • Phone: 734-427-9440
  • Fax: 734-427-1701
Mailing address:
  • Phone: 734-655-1420
  • Fax: 734-655-1445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number4301031560
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: