Provider Demographics
NPI:1144302605
Name:VELASQUEZ, OTTO R (MD)
Entity type:Individual
Prefix:DR
First Name:OTTO
Middle Name:R
Last Name:VELASQUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7019 N 1ST LN
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-1931
Mailing Address - Country:US
Mailing Address - Phone:956-994-6572
Mailing Address - Fax:956-994-0114
Practice Address - Street 1:7019 N 1ST LN
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-1931
Practice Address - Country:US
Practice Address - Phone:956-994-6572
Practice Address - Fax:956-994-0114
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2130208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
G56934Medicare UPIN