Provider Demographics
NPI:1962477661
Name:VELASCO, JONATHAN EARL (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:EARL
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:ONE ELIZABETH PLACE
Mailing Address - Street 2:SUITE 10A
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45408
Mailing Address - Country:US
Mailing Address - Phone:937-228-4126
Mailing Address - Fax:937-228-0247
Practice Address - Street 1:ONE ELIZABETH PLACE
Practice Address - Street 2:SUITE 10A
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45408
Practice Address - Country:US
Practice Address - Phone:937-228-4126
Practice Address - Fax:937-228-0247
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35071454208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0459650Medicaid
OH0459650Medicaid
OHH331080Medicare PIN
OHG67756Medicare UPIN