Provider Demographics
NPI:1831636133
Name:AMEZQUITA VELAZQUEZ, MAURICIO ERNESTO
Entity Type:Individual
Prefix:
First Name:MAURICIO
Middle Name:ERNESTO
Last Name:AMEZQUITA VELAZQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 S BASCOM AVE
Mailing Address - Street 2:APT. E-2
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-5540
Mailing Address - Country:US
Mailing Address - Phone:408-796-2979
Mailing Address - Fax:
Practice Address - Street 1:256 E HAMILTON AVE STE C
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-0237
Practice Address - Country:US
Practice Address - Phone:844-322-4823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program