Provider Demographics
NPI:1245257955
Name:VELAZCO, RENE C (MD)
Entity type:Individual
Prefix:
First Name:RENE
Middle Name:C
Last Name:VELAZCO
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 1:4215 RUTGERS LN
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2913
Mailing Address - Country:US
Mailing Address - Phone:847-205-0561
Mailing Address - Fax:773-334-4931
Practice Address - Street 1:5137 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-3009
Practice Address - Country:US
Practice Address - Phone:773-334-3767
Practice Address - Fax:773-334-4931
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD15863Medicare UPIN
IL744490Medicare ID - Type Unspecified