Provider Demographics
NPI:1972800209
Name:EVANGELISTA, MARK VICTOR (PT)
Entity type:Individual
Prefix:
First Name:MARK VICTOR
Middle Name:
Last Name:EVANGELISTA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 METROPOLITAN AVE
Mailing Address - Street 2:7H
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-7447
Mailing Address - Country:US
Mailing Address - Phone:347-657-0450
Mailing Address - Fax:
Practice Address - Street 1:1409 METROPOLITAN AVE
Practice Address - Street 2:7H
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-7447
Practice Address - Country:US
Practice Address - Phone:347-657-0450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0293241225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist