Provider Demographics
NPI:1053469403
Name:VELASCO, BONNIE (DC, MS)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:
Last Name:VELASCO
Suffix:
Gender:F
Credentials:DC, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-4219
Mailing Address - Country:US
Mailing Address - Phone:973-759-2225
Mailing Address - Fax:973-759-5061
Practice Address - Street 1:24 HARRISON ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-4219
Practice Address - Country:US
Practice Address - Phone:973-759-2225
Practice Address - Fax:973-759-5061
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00555600111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8555001Medicaid
NJU76061Medicare UPIN
NJ8555001Medicaid
NJ033892Medicare ID - Type Unspecified