Provider Demographics
NPI:1275845570
Name:VELASCO, OMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:OMAR
Middle Name:
Last Name: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 1:1206 BARFORD AVE
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-2303
Mailing Address - Country:US
Mailing Address - Phone:626-392-1432
Mailing Address - Fax:
Practice Address - Street 1:1206 BARFORD AVE
Practice Address - Street 2:
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745-2303
Practice Address - Country:US
Practice Address - Phone:626-392-1432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-02
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ57046207R00000X
CAA168081207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ450101Medicaid