Healthcare Provider Details

I. General information

NPI: 1184307506
Provider Name (Legal Business Name): JORGE RAZO VELAZQUEZ DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2023
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6743 W GREENFIELD AVE
WEST ALLIS WI
53214-4966
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 414-381-1990
  • Fax: 414-381-1991
Mailing address:
  • Phone: 586-350-2644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number16498
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: