1205809233 NPI number — OCTAVIO JUAN PEREZ-VELASCO MD

Table of content: OCTAVIO JUAN PEREZ-VELASCO MD (NPI 1205809233)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205809233 NPI number — OCTAVIO JUAN PEREZ-VELASCO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEREZ-VELASCO
Provider First Name:
OCTAVIO
Provider Middle Name:
JUAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1205809233
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1312 W FLETCHER AVE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33612-3366
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-964-0595
Provider Business Mailing Address Fax Number:
813-963-5071

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1312 W FLETCHER AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33612-3366
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-964-0595
Provider Business Practice Location Address Fax Number:
813-963-5071
Provider Enumeration Date:
02/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME81174 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 51903 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 5495696 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P00027558 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: ME81174 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 10636201 . This is a "CITRUS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 5903996 . This is a "GHI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 37439 . This is a "AMERIGROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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