Provider Demographics
NPI:1356541197
Name:VELASCO MASSON, JAIME LUIS (MD)
Entity type:Individual
Prefix:DR
First Name:JAIME
Middle Name:LUIS
Last Name:VELASCO MASSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JAIME
Other - Middle Name:LUIS
Other - Last Name:VELASCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1465 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1003
Mailing Address - Country:US
Mailing Address - Phone:314-268-4101
Mailing Address - Fax:314-577-5379
Practice Address - Street 1:17600 INTERSTATE 45 S
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77384-5148
Practice Address - Country:US
Practice Address - Phone:314-268-4101
Practice Address - Fax:314-577-5379
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR6499207P00000X, 2080P0204X
MO2013021824208000000X
KYC1732208000000X, 2080P0204X
MI4301096765208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics