Provider Demographics
NPI:1386630366
Name:VELASCO, JOSE M (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:M
Last Name:VELASCO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:9669 KENTON AVE
Mailing Address - Street 2:SUITE #204
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1266
Mailing Address - Country:US
Mailing Address - Phone:847-982-1095
Mailing Address - Fax:847-982-1098
Practice Address - Street 1:9669 KENTON AVE
Practice Address - Street 2:SUITE #204
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1266
Practice Address - Country:US
Practice Address - Phone:847-982-1095
Practice Address - Fax:847-982-1098
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2008-12-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036055695208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036055695Medicaid
ILC37947Medicare UPIN
IL036055695Medicaid