Provider Demographics
NPI:1023210721
Name:PENELOPE VELASCO MD
Entity Type:Organization
Organization Name:PENELOPE VELASCO MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PENELOPE
Authorized Official - Middle Name:
Authorized Official - Last Name:VELASCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-608-4898
Mailing Address - Street 1:3660 E IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-2653
Mailing Address - Country:US
Mailing Address - Phone:310-608-4898
Mailing Address - Fax:310-608-4884
Practice Address - Street 1:3660 E IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2653
Practice Address - Country:US
Practice Address - Phone:310-608-4898
Practice Address - Fax:310-608-4884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74761207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI22673Medicare UPIN
CAA74761Medicare ID - Type Unspecified