Provider Demographics
NPI:1407413487
Name:ADRIAN VELASQUEZ MD LLC
Entity Type:Organization
Organization Name:ADRIAN VELASQUEZ MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VELASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-816-0169
Mailing Address - Street 1:581 MASSACHUSETTS AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-1479
Mailing Address - Country:US
Mailing Address - Phone:617-816-0169
Mailing Address - Fax:
Practice Address - Street 1:2110 DORCHESTER AVE STE 205
Practice Address - Street 2:SETON BUILDING
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124
Practice Address - Country:US
Practice Address - Phone:617-816-0169
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-24
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110130458AMedicaid