Healthcare Provider Details

I. General information

NPI: 1982689147
Provider Name (Legal Business Name): JESUS VELASQUEZ MALLARI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5483 PAPAGALLO DR
OCEANSIDE CA
92057-1907
US

IV. Provider business mailing address

3551 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234-4504
US

V. Phone/Fax

Practice location:
  • Phone: 760-231-1611
  • Fax:
Mailing address:
  • Phone: 210-539-9582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301047321
License Number StateFM
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301047321
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: