MEDICARE: DR. JESUS VELASQUEZ MALLARI M.D.

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	208000000X	Pediatrics Physician	4301047321	FM
2	208000000X	Pediatrics Physician	4301047321	MI

General Provider Information

NPI Number	:	1982689147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESUS VELASQUEZ MALLARI M.D.

Provider Business Mailing Address
First Line	:	3551 ROGER BROOKE DR
Second Line	:
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-4504
Country	:	US
Telephone Number	:	210-539-9582
Fax Number	:

Provider Business Practice Location Address
First Line	:	5483 PAPAGALLO DR
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92057-1907
Country	:	US
Telephone Number	:	760-231-1611
Fax Number	:

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

Provider Enumeration Date	:	12/09/2005
Last Update Date	:	01/13/2021

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