Provider Demographics
NPI:1376731968
Name:VELASCO DI DOMENICO, JOSE CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:CARLOS
Last Name:VELASCO DI DOMENICO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOSE
Other - Middle Name:
Other - Last Name:VELASCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2000 PINE ST
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79601-2434
Mailing Address - Country:US
Mailing Address - Phone:325-670-6340
Mailing Address - Fax:833-437-1272
Practice Address - Street 1:2000 PINE ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-2434
Practice Address - Country:US
Practice Address - Phone:325-670-6340
Practice Address - Fax:833-437-1272
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-37190207R00000X, 207RH0000X, 207RH0002X, 207RX0202X
TXT7760207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201099520BMedicaid
KS16701016OtherMEDICARE
OK200587760AMedicaid
KS201099520AMedicaid
KSKA3434005OtherMEDICARE