Healthcare Provider Details

I. General information

NPI: 1508854472
Provider Name (Legal Business Name): PETER THOMAS EVANGELISTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 METRO CENTER BLVD STE 2000
WARWICK RI
02886-1785
US

IV. Provider business mailing address

125 METRO CENTER BLVD STE 2000
WARWICK RI
02886-1785
US

V. Phone/Fax

Practice location:
  • Phone: 401-432-2520
  • Fax: 401-453-8220
Mailing address:
  • Phone: 401-432-2520
  • Fax: 401-453-8220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD11408
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number217024
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: