Basic Information
| Provider Information | |||||||||
| NPI: | 1497802458 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VELASQUEZ | ||||||||
| FirstName: | VICTOR | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1740 CLEVELAND RD | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446912204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302874500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1740 CLEVELAND RD | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446912204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302874500 | ||||||||
| FaxNumber: | 3302649804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 04/01/2008 | ||||||||
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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 | 207R00000X | 35079082 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2228468 | 05 | OH | MEDICAID |