Provider Demographics
NPI:1881776367
Name:OTTO VELASQUEZ MD PHD & ASSOCIATES
Entity type:Organization
Organization Name:OTTO VELASQUEZ MD PHD & ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OTTO
Authorized Official - Middle Name:R
Authorized Official - Last Name:VELASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:877-543-7247
Mailing Address - Street 1:5111 N 10TH ST # 281
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-2835
Mailing Address - Country:US
Mailing Address - Phone:877-543-7247
Mailing Address - Fax:956-994-0114
Practice Address - Street 1:5111 N 10TH ST # 281
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-2835
Practice Address - Country:US
Practice Address - Phone:877-543-7247
Practice Address - Fax:956-994-0114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2080P0205X
TXK2130208000000X, 2080P0205X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric EndocrinologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX167227101Medicaid