Healthcare Provider Details

I. General information

NPI: 1396734091
Provider Name (Legal Business Name): RICARDO S VELASQUEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 03/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 MARKET ST
ALAMOSA CO
81101
US

IV. Provider business mailing address

128 MARKET ST
ALAMOSA CO
81101-2290
US

V. Phone/Fax

Practice location:
  • Phone: 719-589-5161
  • Fax: 719-589-5722
Mailing address:
  • Phone: 719-589-5161
  • Fax: 719-589-5722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21102
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: