Healthcare Provider Details

I. General information

NPI: 1861311573
Provider Name (Legal Business Name): JERARDY IVAN VELASQUEZ-BRAVO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6180 UNIVERSITY PKWY UNIT 3905
FORT POLK LA
71459-3118
US

IV. Provider business mailing address

6180 UNIVERSITY PKWY UNIT 3905
FORT POLK LA
71459-3118
US

V. Phone/Fax

Practice location:
  • Phone: 757-709-5503
  • Fax:
Mailing address:
  • Phone: 757-709-5503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: