Provider Demographics
NPI:1851437560
Name:VELAZQUEZ, MARK PHILIP
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:PHILIP
Last Name: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 1:11 ORMAND AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-4412
Mailing Address - Country:US
Mailing Address - Phone:631-834-1208
Mailing Address - Fax:
Practice Address - Street 1:11 ORMAND AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-4412
Practice Address - Country:US
Practice Address - Phone:631-834-1208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NY251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
No174400000XOther Service ProvidersSpecialist