Provider Demographics
NPI:1588690929
Name:EVANGELISTA, CLEOFE P (MD)
Entity type:Individual
Prefix:MRS
First Name:CLEOFE
Middle Name:P
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 OXFORD VALLEY RD
Mailing Address - Street 2:SUITE 403A
Mailing Address - City:YARDLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19067-7706
Mailing Address - Country:US
Mailing Address - Phone:215-321-0580
Mailing Address - Fax:215-321-9098
Practice Address - Street 1:301 OXFORD VALLEY RD
Practice Address - Street 2:SUITE 403A
Practice Address - City:YARDLEY
Practice Address - State:PA
Practice Address - Zip Code:19067-7706
Practice Address - Country:US
Practice Address - Phone:215-321-0580
Practice Address - Fax:215-321-9098
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030470E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB40447Medicare UPIN
PAEV533188Medicare ID - Type Unspecified