Provider Demographics
NPI:1720042906
Name:VELASCO, REYNALDO (MD)
Entity Type:Individual
Prefix:DR
First Name:REYNALDO
Middle Name:
Last Name:VELASCO
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 1:402 LIPPINCOTT DR
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4112
Mailing Address - Country:US
Mailing Address - Phone:856-782-3300
Mailing Address - Fax:856-504-8029
Practice Address - Street 1:504 WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:WEST COLLINGSWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08107-1730
Practice Address - Country:US
Practice Address - Phone:856-424-6050
Practice Address - Fax:856-424-2943
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05578200208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
077356 SK3Medicare PIN