Healthcare Provider Details

I. General information

NPI: 1740404706
Provider Name (Legal Business Name): PROVIANA ORTIZ VELAZQUEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

V1 CALLE 16 URB. VILLA LOS SANTOS
ARECIBO PR
00612-3112
US

IV. Provider business mailing address

C33 CALLE 3 HILL SIDE
RIO PIEDRAS PR
00926-5205
US

V. Phone/Fax

Practice location:
  • Phone: 787-879-1585
  • Fax: 787-879-4315
Mailing address:
  • Phone: 787-879-1585
  • Fax: 787-879-4315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number6342
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: