Healthcare Provider Details

I. General information

NPI: 1629073952
Provider Name (Legal Business Name): P JOEL VELASCO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 SPRINGHURST BLVD STE 101
LOUISVILLE KY
40241-6137
US

IV. Provider business mailing address

3801 SPRINGHURST BLVD STE 101
LOUISVILLE KY
40241-6137
US

V. Phone/Fax

Practice location:
  • Phone: 502-423-7222
  • Fax: 502-423-7277
Mailing address:
  • Phone: 502-394-0101
  • Fax: 502-425-4275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number30468
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: