Provider Demographics
NPI:1629212295
Name:VELASQUEZ, MARIEBETH BANGOY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIEBETH
Middle Name:BANGOY
Last Name:VELASQUEZ
Suffix:
Gender:F
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:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-543-6420
Mailing Address - Fax:
Practice Address - Street 1:4915 25TH AVE NE
Practice Address - Street 2:SUITE 300-W
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-5667
Practice Address - Country:US
Practice Address - Phone:206-525-7777
Practice Address - Fax:206-520-3288
Is Sole Proprietor?:No
Enumeration Date:2009-04-27
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2011-0765207Q00000X
WAMD60428752207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1629212295Medicaid