Provider Demographics
NPI:1730638602
Name:EVANGELISTA, JOSE RODNEY
Entity type:Individual
Prefix:
First Name:JOSE RODNEY
Middle Name:
Last Name:EVANGELISTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2209 CARR DR
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-9543
Mailing Address - Country:US
Mailing Address - Phone:765-210-0633
Mailing Address - Fax:
Practice Address - Street 1:2209 CARR DR
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-9543
Practice Address - Country:US
Practice Address - Phone:765-210-0633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist