Provider Demographics
NPI:1861496390
Name:VELASCO, JOSE PINLAC (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:PINLAC
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:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37857-0850
Mailing Address - Country:US
Mailing Address - Phone:423-921-6975
Mailing Address - Fax:423-921-6920
Practice Address - Street 1:737 E SEVIER AVE
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4912
Practice Address - Country:US
Practice Address - Phone:423-246-7922
Practice Address - Fax:423-246-4248
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26079207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
4057104OtherBCBST
TN3087701Medicaid
3703865Medicare PIN
4057104OtherBCBST
TN3087703Medicare ID - Type Unspecified
TN3087701Medicaid
3716673Medicare PIN
30877011Medicare PIN