Provider Demographics
NPI:1093770992
Name:VELASCO, LUIS M (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:M
Last Name:VELASCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-7854
Mailing Address - Fax:260-458-5664
Practice Address - Street 1:420 N SAWYER RD
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-2572
Practice Address - Country:US
Practice Address - Phone:260-347-8030
Practice Address - Fax:260-347-8035
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY26945207V00000X
IN01045543A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY117874OtherPASSPORT OB/GYN / CMA DBA
KY3936751OtherCIGNA / CMA DBA
KY000052153AOtherHUMANA / CMA DBA
KY1112965OtherPASSPORT PCP / CMA DBA
KY64269459Medicaid
KY000000350600OtherANTHEM / CMA DBA
KY023334OtherSIHO / CMA DBA
IN200005440Medicaid
KY1189995OtherCHA / CMA DBA
KY2436563000OtherPASSORT ADVANTAGE OB/GYN / CMA DBA
KY2436792000OtherPASSPORT ADVANTAGE PCP / CMA DBA
KY1189995OtherCHA / CMA DBA
KY0361964Medicare PIN