Provider Demographics
NPI:1326225723
Name:JONATHAN VELASQUEZ, MD, PC
Entity Type:Organization
Organization Name:JONATHAN VELASQUEZ, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VELASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-224-3322
Mailing Address - Street 1:1118 MORNINGSIDE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069-4948
Mailing Address - Country:US
Mailing Address - Phone:478-224-3322
Mailing Address - Fax:478-224-3325
Practice Address - Street 1:1118 MORNINGSIDE DR
Practice Address - Street 2:SUITE A
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-4948
Practice Address - Country:US
Practice Address - Phone:478-224-3322
Practice Address - Fax:478-224-3325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048581207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH43209Medicare UPIN
GA511G700355Medicare PIN