Provider Demographics
NPI:1790953271
Name:NELLY VELASQUEZ,MD,PA
Entity Type:Organization
Organization Name:NELLY VELASQUEZ,MD,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NELLY
Authorized Official - Middle Name:DEL CARMEN
Authorized Official - Last Name:VELASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-236-1100
Mailing Address - Street 1:900 E 30TH ST STE 205
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-3378
Mailing Address - Country:US
Mailing Address - Phone:512-236-1100
Mailing Address - Fax:512-236-1128
Practice Address - Street 1:900 E 30TH ST STE 205
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705
Practice Address - Country:US
Practice Address - Phone:512-236-1100
Practice Address - Fax:512-236-1128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-18
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8547207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165096201Medicaid