Provider Demographics
NPI:1891945580
Name:VELAZQUEZ VICENTE, LUIS J (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:J
Last Name:VELAZQUEZ VICENTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:111 WEBB DR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-3962
Mailing Address - Country:US
Mailing Address - Phone:863-588-1424
Mailing Address - Fax:888-972-1752
Practice Address - Street 1:4120 US HIGHWAY 98 N
Practice Address - Street 2:SUITE 200
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-3854
Practice Address - Country:US
Practice Address - Phone:863-940-3147
Practice Address - Fax:863-940-3141
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17355208D00000X
FLACN587208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLACN587OtherMEDICINE DOCTOR LIC