Provider Demographics
NPI:1598476525
Name:VELASCO, JAVIER
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:
Last Name:VELASCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 HERMOSA DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-6536
Mailing Address - Country:US
Mailing Address - Phone:208-569-4513
Mailing Address - Fax:
Practice Address - Street 1:117 E 19TH ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5151
Practice Address - Country:US
Practice Address - Phone:575-627-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-12
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program