Basic Information
| Provider Information | |||||||||
| NPI: | 1780696765 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VELARDE | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | S C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 165 N CHURCH RD | ||||||||
| Address2: | |||||||||
| City: | BENSENVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601062009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307059554 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 165 N CHURCH RD | ||||||||
| Address2: | |||||||||
| City: | BENSENVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601062009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302381111 | ||||||||
| FaxNumber: | 6302380164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 05/20/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 016003948 | IL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 016003948 | 05 | IL | MEDICAID |