Healthcare Provider Details

I. General information

NPI: 1992898175
Provider Name (Legal Business Name): ROMEO VELASCO TAMAYO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 11/02/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 MAIN ST
RAVENA NY
12143-1930
US

IV. Provider business mailing address

33 MAIN ST
RAVENA NY
12143-1930
US

V. Phone/Fax

Practice location:
  • Phone: 518-756-6175
  • Fax: 518-756-6176
Mailing address:
  • Phone: 518-756-6175
  • Fax: 518-756-6176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number127704
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: