Provider Demographics
NPI:1396931275
Name:VELAZQUEZ VICENTE, MARISSEL (MD)
Entity type:Individual
Prefix:DR
First Name:MARISSEL
Middle Name:
Last Name:VELAZQUEZ VICENTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 NW 167TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5710
Mailing Address - Country:US
Mailing Address - Phone:941-357-7950
Mailing Address - Fax:941-840-1003
Practice Address - Street 1:1505 53RD AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203-4249
Practice Address - Country:US
Practice Address - Phone:941-357-7950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-24
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME135986207R00000X, 207RP1001X
OH35.136627207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR7327OtherSTATE MD LICENSE
PR0098899Medicare PIN