Healthcare Provider Details

I. General information

NPI: 1184487811
Provider Name (Legal Business Name): ALEXANDER VELAZQUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2024
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

849 FAIRVIEW ST
JACKSON MS
39202-1627
US

IV. Provider business mailing address

203 LYON TREE WAY
VICKSBURG MS
39180-5820
US

V. Phone/Fax

Practice location:
  • Phone: 601-415-2619
  • Fax:
Mailing address:
  • Phone: 601-415-2619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberT-6190
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: