Basic Information
| Provider Information | |||||||||
| NPI: | 1326007782 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VELASCO | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 W MCKINLEY AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178766600 | ||||||||
| FaxNumber: | 2178766606 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 W MCKINLEY AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178766600 | ||||||||
| FaxNumber: | 2178766606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 02/12/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | 036104082 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 036104082 | 05 | IL | MEDICAID |