Healthcare Provider Details

I. General information

NPI: 1205979515
Provider Name (Legal Business Name): MAXIMILIANO VELASCO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10095 N KENDALL DR STE 103
MIAMI FL
33176
US

IV. Provider business mailing address

PO BOX 430885
SOUTH MIAMI FL
33243-0885
US

V. Phone/Fax

Practice location:
  • Phone: 786-504-0904
  • Fax: 786-504-0899
Mailing address:
  • Phone: 786-456-4107
  • Fax: 786-376-8908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberME95957
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: