Provider Demographics
NPI:1811120223
Name:VELAZQUEZ, LIZBETH
Entity type:Individual
Prefix:
First Name:LIZBETH
Middle Name:
Last Name:VELAZQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-2423
Mailing Address - Country:US
Mailing Address - Phone:801-941-0668
Mailing Address - Fax:
Practice Address - Street 1:391 MADISON AVE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-2423
Practice Address - Country:US
Practice Address - Phone:801-941-0668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT876000308007Medicaid
UT260022408OtherRAILROAD MEDICARE
UT260022408OtherRAILROAD MEDICARE