Healthcare Provider Details

I. General information

NPI: 1093770992
Provider Name (Legal Business Name): LUIS M VELASCO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 N SAWYER RD
KENDALLVILLE IN
46755-2572
US

IV. Provider business mailing address

1234 E DUPONT RD SUITE 1
FORT WAYNE IN
46825-1545
US

V. Phone/Fax

Practice location:
  • Phone: 260-347-8030
  • Fax: 260-347-8035
Mailing address:
  • Phone: 260-373-7854
  • Fax: 260-458-5664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number26945
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01045543A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: