Healthcare Provider Details

I. General information

NPI: 1609195635
Provider Name (Legal Business Name): LUIS VELASQUEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2010
Last Update Date: 12/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11449 SUTPHIN BLVD
JAMAICA NY
11434-1022
US

IV. Provider business mailing address

11449 SUTPHIN BLVD
JAMAICA NY
11434-1022
US

V. Phone/Fax

Practice location:
  • Phone: 718-723-4173
  • Fax:
Mailing address:
  • Phone: 718-945-7150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number255407
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: