MEDICARE: TITO VELASQUEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	9112704	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9112704	OTHER	FL	NCCPA FLORIDA STATE LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013551266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TITO VELASQUEZ

Provider Business Mailing Address
First Line	:	1160 N FEDERAL HWY APT 1023
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-1436
Country	:	US
Telephone Number	:	312-833-1183
Fax Number	:

Provider Business Practice Location Address
First Line	:	1160 N FEDERAL HWY APT 1023
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-1436
Country	:	US
Telephone Number	:	312-833-1183
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2019
Last Update Date	:	12/10/2019

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Directions to “ TITO VELASQUEZ ” Practice Location

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