Healthcare Provider Details

I. General information

NPI: 1295120509
Provider Name (Legal Business Name): DHYANA VELASCO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4705 MONTGOMERY BLVD NE STE 301
ALBUQUERQUE NM
87109-1234
US

IV. Provider business mailing address

1013 GIRARD BLVD NE
ALBUQUERQUE NM
87106-2014
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-4500
  • Fax: 505-727-4505
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD2019-0767
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: