Provider Demographics
NPI:1871998385
Name:JOSE S EVANGELISTA III MD PC
Entity type:Organization
Organization Name:JOSE S EVANGELISTA III MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:S
Authorized Official - Last Name:EVANGELISTA
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:248-890-9995
Mailing Address - Street 1:7071 ORCHARD LAKE RD
Mailing Address - Street 2:SUITE 333
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3613
Mailing Address - Country:US
Mailing Address - Phone:248-890-9995
Mailing Address - Fax:
Practice Address - Street 1:7071 ORCHARD LAKE RD
Practice Address - Street 2:SUITE 333
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3613
Practice Address - Country:US
Practice Address - Phone:248-890-9995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI05865R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty