Basic Information
Provider Information | |||||||||
NPI: | 1861496390 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VELASCO | ||||||||
FirstName: | JOSE | ||||||||
MiddleName: | PINLAC | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 850 | ||||||||
Address2: |   | ||||||||
City: | ROGERSVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 378570850 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4232725202 | ||||||||
FaxNumber: | 4232724696 | ||||||||
Practice Location | |||||||||
Address1: | 4307 HIGHWAY 66 S | ||||||||
Address2: |   | ||||||||
City: | ROGERSVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 378573155 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4239211600 | ||||||||
FaxNumber: | 4239211675 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2005 | ||||||||
LastUpdateDate: | 02/28/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 26079 | TN | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 4057104 | 01 |   | BCBST | OTHER | 3087701 | 05 | TN |   | MEDICAID |