Provider Demographics
NPI:1194028373
Name:ALFREDO C VELASQUEZ MD PLLC
Entity Type:Organization
Organization Name:ALFREDO C VELASQUEZ MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALFREDO
Authorized Official - Middle Name:C
Authorized Official - Last Name:VELASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-345-3378
Mailing Address - Street 1:209 WASHINGTON ST W
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-2345
Mailing Address - Country:US
Mailing Address - Phone:304-345-3378
Mailing Address - Fax:304-344-4420
Practice Address - Street 1:209 WASHINGTON ST W
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-2345
Practice Address - Country:US
Practice Address - Phone:304-345-3378
Practice Address - Fax:304-344-4420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-10
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV9189174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0089466000Medicaid
WV0089466000Medicaid