Provider Demographics
NPI:1730163353
Name:EVIDENTE, VIRGILIO H (MD)
Entity type:Individual
Prefix:DR
First Name:VIRGILIO
Middle Name:H
Last Name:EVIDENTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9590 E IRONWOOD SQUARE DR STE 225
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4599
Mailing Address - Country:US
Mailing Address - Phone:480-526-5441
Mailing Address - Fax:
Practice Address - Street 1:9590 E IRONWOOD SQUARE DR STE 225
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4599
Practice Address - Country:US
Practice Address - Phone:480-526-5441
Practice Address - Fax:480-526-5443
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ244382084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ130013882OtherRAILROAD MEDICARE
AZ356247Medicaid
AZ86080015085259A016OtherTRIWEST
AZ86080015085259A016OtherTRIWEST
AZ356247Medicaid