Provider Demographics
NPI:1063919249
Name:VELAZQUEZ, MIRIAM A (DO)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:A
Last Name:VELAZQUEZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 SAN BERNARDINO RD
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4920
Mailing Address - Country:US
Mailing Address - Phone:909-981-2811
Mailing Address - Fax:
Practice Address - Street 1:999 SAN BERNARDINO RD
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4920
Practice Address - Country:US
Practice Address - Phone:909-985-2811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A19380207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology