Basic Information
| Provider Information | |||||||||
| NPI: | 1275519456 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VELASQUEZ | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | SILVA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1890 | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786291390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306726511 | ||||||||
| FaxNumber: | 8306726430 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 S LAUREL AVE | ||||||||
| Address2: | |||||||||
| City: | LULING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786482624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8308756399 | ||||||||
| FaxNumber: | 8308756398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2005 | ||||||||
| LastUpdateDate: | 11/28/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | K0391 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 120675706 | 05 | TX | MEDICAID |