Basic Information
| Provider Information | |||||||||
| NPI: | 1083664262 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANGELISTA | ||||||||
| FirstName: | BAYANI | ||||||||
| MiddleName: | V. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 910329 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921910329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585641400 | ||||||||
| FaxNumber: | 8585641500 | ||||||||
| Practice Location | |||||||||
| Address1: | 39000 BOB HOPE DR | ||||||||
| Address2: | EISENHOWER IMAGING CENTER | ||||||||
| City: | RANCHO MIRAGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922703221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603403911 | ||||||||
| FaxNumber: | 7606743852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 05/08/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A85985 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00A859850 | 01 | CA | BLUE SHIELD OF CA | OTHER | 00A859850 | 05 | CA | MEDICAID |