Basic Information
| Provider Information | |||||||||
| NPI: | 1891945580 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VELAZQUEZ VICENTE | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 WEBB DR | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338373962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635881424 | ||||||||
| FaxNumber: | 8889721752 | ||||||||
| Practice Location | |||||||||
| Address1: | 4120 US HIGHWAY 98 N | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338093854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8639403147 | ||||||||
| FaxNumber: | 8639403141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2008 | ||||||||
| LastUpdateDate: | 09/01/2016 | ||||||||
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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 | 208D00000X | 17355 | PR | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | ACN587 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | ACN587 | 01 | FL | MEDICINE DOCTOR LIC | OTHER |