Healthcare Provider Details

I. General information

NPI: 1619460391
Provider Name (Legal Business Name): CAMILO VELASQUEZ MEJIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 23RD ST STE 520
ASHLAND KY
41101-2878
US

IV. Provider business mailing address

5323 HARRY HINES BLVD
DALLAS TX
75390-8879
US

V. Phone/Fax

Practice location:
  • Phone: 606-326-1675
  • Fax:
Mailing address:
  • Phone: 214-645-7708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberBP1-0063442
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number61243
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: