Provider Demographics
NPI:1548295108
Name:VELAZQUEZ CLINIC LTD
Entity type:Organization
Organization Name:VELAZQUEZ CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:VELAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-931-0300
Mailing Address - Street 1:1185 DUNDEE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-2232
Mailing Address - Country:US
Mailing Address - Phone:847-931-0300
Mailing Address - Fax:847-931-0303
Practice Address - Street 1:1185 DUNDEE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-2232
Practice Address - Country:US
Practice Address - Phone:847-931-0300
Practice Address - Fax:847-931-0303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4532225OtherBLUE CROSS/BLUE SHIELD
IL210762Medicare PIN