Healthcare Provider Details

I. General information

NPI: 1982087961
Provider Name (Legal Business Name): BERNARDINO VELASQUEZ MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7878 N 16TH ST
PHOENIX AZ
85020-4449
US

IV. Provider business mailing address

PO BOX 39179
PHOENIX AZ
85069-9179
US

V. Phone/Fax

Practice location:
  • Phone: 602-395-0718
  • Fax: 602-277-8146
Mailing address:
  • Phone: 602-395-0718
  • Fax: 602-277-8146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number49851
License Number StateAZ

VIII. Authorized Official

Name: BERNARDINO VELASQUEZ
Title or Position: MD
Credential:
Phone: 60239590718