Basic Information
| Provider Information | |||||||||
| NPI: | 1730111386 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VELASCO | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | RICARDO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2007 S ZAPATA HWY | ||||||||
| Address2: | |||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780466510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567958100 | ||||||||
| FaxNumber: | 9567958135 | ||||||||
| Practice Location | |||||||||
| Address1: | 1515 PAPPAS ST | ||||||||
| Address2: | |||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780411705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567958100 | ||||||||
| FaxNumber: | 9567958135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 12/03/2015 | ||||||||
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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 | 207Q00000X | M2171 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 176204901 | 01 | TX | MEDICAID TPI | OTHER | M2171 | 01 | TX | LICENSE | OTHER |