Healthcare Provider Details

I. General information

NPI: 1669693081
Provider Name (Legal Business Name): EDGAR J EVANGELISTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 E FLAMINGO RD STE 201
LAS VEGAS NV
89119-5192
US

IV. Provider business mailing address

1452 W HORIZON RIDGE PKWY # 566
HENDERSON NV
89012-4422
US

V. Phone/Fax

Practice location:
  • Phone: 702-800-7831
  • Fax: 877-409-2014
Mailing address:
  • Phone: 702-800-7831
  • Fax: 877-409-2014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084D0003X
TaxonomyDiagnostic Neuroimaging (Psychiatry & Neurology) Physician
License Number12377
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number12377
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number12377
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: