Healthcare Provider Details

I. General information

NPI: 1245751809
Provider Name (Legal Business Name): JUAN HORACIO VELASQUEZ LOPEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 11/10/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

910 SHERIDAN AVE APT 4A
BRONX NY
10451-3330
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-2005
  • Fax: 601-815-0434
Mailing address:
  • Phone: 718-926-9223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number31029
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number31029
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: