Provider Demographics
NPI:1396740536
Name:VELASCO, ALFONSO (MD)
Entity type:Individual
Prefix:DR
First Name:ALFONSO
Middle Name:
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 1:4011 N FRESNO ST
Mailing Address - Street 2:STE 101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-4028
Mailing Address - Country:US
Mailing Address - Phone:559-227-6691
Mailing Address - Fax:559-227-3765
Practice Address - Street 1:4011 N FRESNO ST
Practice Address - Street 2:STE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-4028
Practice Address - Country:US
Practice Address - Phone:559-227-6691
Practice Address - Fax:559-227-3765
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29360207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A293600Medicaid
CA00A293600Medicare ID - Type Unspecified
CAE91224Medicare UPIN