Healthcare Provider Details

I. General information

NPI: 1669670543
Provider Name (Legal Business Name): ECTIS A VELAZQUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 09/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5955 PONCE DE LEON BLVD
CORAL GABLES FL
33146-2423
US

IV. Provider business mailing address

5955 PONCE DE LEON BLVD
CORAL GABLES FL
33146-2423
US

V. Phone/Fax

Practice location:
  • Phone: 305-661-1515
  • Fax: 305-663-5948
Mailing address:
  • Phone: 305-661-1515
  • Fax: 305-663-5948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberME94703
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: