1114378874 NPI number — LUIS VELAZQUEZ MD PLLC

Table of content: (NPI 1114378874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114378874 NPI number — LUIS VELAZQUEZ MD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUIS VELAZQUEZ MD PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114378874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1815 E LAKE MEAD BLVD STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
N LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89030-7193
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1815 E LAKE MEAD BLVD
Provider Second Line Business Practice Location Address:
SUITE 317
Provider Business Practice Location Address City Name:
N LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89030-7187
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-960-4150
Provider Business Practice Location Address Fax Number:
702-960-4154
Provider Enumeration Date:
06/23/2016

Additional Information

Authorized Official

Authorized Official Last Name:
VELAZQUEZ
Authorized Official First Name:
LUIS
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN OWNER/MANAGER
Authorized Official Telephone Number:
305-924-5198

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  14692 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X , with the licence number: 14642 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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