Healthcare Provider Details

I. General information

NPI: 1962477661
Provider Name (Legal Business Name): JONATHAN EARL VELASCO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3533 SOUTHERN BLVD STE 2200
DAYTON OH
45429-1264
US

IV. Provider business mailing address

1 PRESTIGE PL STE 550
MIAMISBURG OH
45342-6115
US

V. Phone/Fax

Practice location:
  • Phone: 937-228-4126
  • Fax: 937-424-8659
Mailing address:
  • Phone: 937-762-1310
  • Fax: 937-522-8068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35071454
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number35071454
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: