Provider Demographics
NPI:1093917676
Name:DE VELASCO, RAUL E (MD)
Entity Type:Individual
Prefix:DR
First Name:RAUL
Middle Name:E
Last Name:DE VELASCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13150 SW 77TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-6116
Mailing Address - Country:US
Mailing Address - Phone:305-256-3809
Mailing Address - Fax:
Practice Address - Street 1:13150 SW 77TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-6116
Practice Address - Country:US
Practice Address - Phone:305-256-3809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0013574207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAD4532126OtherDEA
FLAD4532126OtherDEA
FL91824ZMedicare ID - Type Unspecified