Provider Demographics
NPI:1639300197
Name:VELASCO, MOISES (IDMT)
Entity Type:Individual
Prefix:
First Name:MOISES
Middle Name:
Last Name:VELASCO
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 TH MEDICAL GROUP
Mailing Address - Street 2:30 NIGHTINGALE RD.
Mailing Address - City:EDWARDS AFB
Mailing Address - State:CA
Mailing Address - Zip Code:93524-0001
Mailing Address - Country:US
Mailing Address - Phone:661-277-1130
Mailing Address - Fax:
Practice Address - Street 1:412 TH MEDICAL GROUP
Practice Address - Street 2:30 NIGHTINGALE RD.
Practice Address - City:EDWARDS AFB
Practice Address - State:CA
Practice Address - Zip Code:93524-0001
Practice Address - Country:US
Practice Address - Phone:661-277-1130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-31
Last Update Date:2013-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians