1285969790 NPI number — DR. ODETTE DELA CRUZ EVANGELISTA M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285969790 NPI number — DR. ODETTE DELA CRUZ EVANGELISTA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANGELISTA
Provider First Name:
ODETTE
Provider Middle Name:
DELA CRUZ
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285969790
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33663 BAYVIEW MEDICAL DR
Provider Second Line Business Mailing Address:
UNIT 1
Provider Business Mailing Address City Name:
LEWES
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19958-1663
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-645-3555
Provider Business Mailing Address Fax Number:
302-644-3560

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1526 SAVANNAH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWES
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19958-1683
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-645-1806
Provider Business Practice Location Address Fax Number:
302-645-5895
Provider Enumeration Date:
10/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  C1-0010088 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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