Provider Demographics
NPI:1669693081
Name:EVANGELISTA, EDGAR J (MD)
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:J
Last Name:EVANGELISTA
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:1452 W HORIZON RIDGE PKWY # 566
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89012-4422
Mailing Address - Country:US
Mailing Address - Phone:702-800-7831
Mailing Address - Fax:877-409-2014
Practice Address - Street 1:2110 E FLAMINGO RD STE 201
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5192
Practice Address - Country:US
Practice Address - Phone:702-800-7831
Practice Address - Fax:877-409-2014
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2024-05-22
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Provider Licenses
StateLicense IDTaxonomies
NV123772084D0003X, 2084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084D0003XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyDiagnostic Neuroimaging
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCE661YMedicare PIN