Provider Demographics
NPI:1326007782
Name:VELASCO, MARIO R (MD)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:R
Last Name:VELASCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:210 W MCKINLEY AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526
Mailing Address - Country:US
Mailing Address - Phone:217-876-6600
Mailing Address - Fax:217-876-6606
Practice Address - Street 1:210 W MCKINLEY AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526
Practice Address - Country:US
Practice Address - Phone:217-876-6600
Practice Address - Fax:217-876-6606
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036104082207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104082Medicaid
IL036104082Medicaid
L82993Medicare PIN
ILH29275Medicare UPIN
H29275Medicare UPIN