Healthcare Provider Details

I. General information

NPI: 1346530870
Provider Name (Legal Business Name): JOSE VELAZQUEZ VEGA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 06/06/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 JOHNSON FY RD NE
ATLANTA GA
30342-1605
US

IV. Provider business mailing address

1001 JOHNSON FY RD NE
ATLANTA GA
30342-1605
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-2069
  • Fax: 404-785-4541
Mailing address:
  • Phone: 404-785-2069
  • Fax: 404-785-4541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number79756
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: