Provider Demographics
NPI:1205809233
Name:PEREZ-VELASCO, OCTAVIO JUAN (MD)
Entity type:Individual
Prefix:
First Name:OCTAVIO
Middle Name:JUAN
Last Name:PEREZ-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 1:1312 W FLETCHER AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-3366
Mailing Address - Country:US
Mailing Address - Phone:813-964-0595
Mailing Address - Fax:813-963-5071
Practice Address - Street 1:1312 W FLETCHER AVE
Practice Address - Street 2:SUITE A
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-3366
Practice Address - Country:US
Practice Address - Phone:813-964-0595
Practice Address - Fax:813-963-5071
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81174207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL51903OtherBCBS
FL5495696OtherAETNA
FLP00027558OtherRAILROAD MEDICARE
FLME81174OtherMEDICAL LICENSE
FL10636201OtherCITRUS
FL5903996OtherGHI
FL37439OtherAMERIGROUP
FL51903OtherBCBS
G61374Medicare UPIN