Provider Demographics
NPI:1942614599
Name:VELAZQUEZ PEREZ, AGUSTIN GABRIEL
Entity Type:Individual
Prefix:
First Name:AGUSTIN
Middle Name:GABRIEL
Last Name:VELAZQUEZ PEREZ
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 1:4633 AVE. ISLA VERDE APT 303-A COND. CASTILLO DEL MAR
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00979
Mailing Address - Country:US
Mailing Address - Phone:939-639-0967
Mailing Address - Fax:
Practice Address - Street 1:A LA ORDEN SHOPPING CENTER 2ND FL 600
Practice Address - Street 2:
Practice Address - City:TOA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00949
Practice Address - Country:US
Practice Address - Phone:787-710-2532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR31036207R00000X
CAA161591207RN0300X
390200000X
PR22037207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program