Provider Demographics
NPI:1780046672
Name:CARMEN VELAZQUEZ MD INC
Entity Type:Organization
Organization Name:CARMEN VELAZQUEZ MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:VELAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD INC
Authorized Official - Phone:224-829-2717
Mailing Address - Street 1:3507 VALLEY VISTA RD
Mailing Address - Street 2:
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-1120
Mailing Address - Country:US
Mailing Address - Phone:224-829-2717
Mailing Address - Fax:619-512-1295
Practice Address - Street 1:2575 EAST EIGHT STREET
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950
Practice Address - Country:US
Practice Address - Phone:224-829-2717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA56153207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty