Healthcare Provider Details

I. General information

NPI: 1699184671
Provider Name (Legal Business Name): FERNANDO VELAZQUEZ VAZQUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2014
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 GREENBRIER RD
GREEN BAY WI
54311-6519
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-8100
  • Fax:
Mailing address:
  • Phone: 920-288-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number67001
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: