Healthcare Provider Details

I. General information

NPI: 1164632717
Provider Name (Legal Business Name): RAFAEL VELASQUEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12150 SEMINOLE BLVD
LARGO FL
33778-2833
US

IV. Provider business mailing address

5400 PINEHURST DR
SPRING HILL FL
34606-3833
US

V. Phone/Fax

Practice location:
  • Phone: 727-216-6188
  • Fax: 727-216-6242
Mailing address:
  • Phone: 352-277-5348
  • Fax: 352-606-2857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL2694
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-33895
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME119208
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: