Provider Demographics
NPI:1174855449
Name:MIGUEL VELAZQUEZ DO, P.A.
Entity Type:Organization
Organization Name:MIGUEL VELAZQUEZ DO, P.A.
Other - Org Name:OSTEOPATHIC SPORT & SPINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VELAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:207-854-8200
Mailing Address - Street 1:344 CUMBERLAND ST
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04092-2408
Mailing Address - Country:US
Mailing Address - Phone:207-854-8200
Mailing Address - Fax:877-735-2638
Practice Address - Street 1:344 CUMBERLAND ST
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-2408
Practice Address - Country:US
Practice Address - Phone:207-854-8200
Practice Address - Fax:877-735-2638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-11
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1761204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431815799Medicaid
MEME1383Medicare PIN
ME431815799Medicaid