MEDICARE: MARK VICTOR EVANGELISTA PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	0293241	NY

General Provider Information

NPI Number	:	1972800209
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK VICTOR EVANGELISTA PT

Provider Business Mailing Address
First Line	:	1409 METROPOLITAN AVE
Second Line	:	7H
City	:	BRONX
State	:	NY
Zip	:	10462-7447
Country	:	US
Telephone Number	:	347-657-0450
Fax Number	:

Provider Business Practice Location Address
First Line	:	1409 METROPOLITAN AVE
Second Line	:	7H
City	:	BRONX
State	:	NY
Zip	:	10462-7447
Country	:	US
Telephone Number	:	347-657-0450
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2011
Last Update Date	:	02/23/2011

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