Provider Demographics
NPI:1497812895
Name:VELAZQUEZ, JUAN C (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:C
Last Name:VELAZQUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 RONALD ST
Mailing Address - Street 2:
Mailing Address - City:BRAWLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92227-5122
Mailing Address - Country:US
Mailing Address - Phone:760-556-6550
Mailing Address - Fax:
Practice Address - Street 1:1590 S IMPERIAL AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4241
Practice Address - Country:US
Practice Address - Phone:760-352-2551
Practice Address - Fax:888-631-5150
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA053203207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC03830FMedicaid
CA1609118041Medicaid