Provider Demographics
NPI:1194766105
Name:VELAZQUEZ LOPEZ, FABIAN
Entity type:Individual
Prefix:
First Name:FABIAN
Middle Name:
Last Name:VELAZQUEZ LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:288 AVE LAURO PINERO
Mailing Address - Street 2:
Mailing Address - City:CEIBA
Mailing Address - State:PR
Mailing Address - Zip Code:00735-2706
Mailing Address - Country:US
Mailing Address - Phone:787-885-3525
Mailing Address - Fax:787-885-3525
Practice Address - Street 1:288 AVE LAURO PINERO
Practice Address - Street 2:
Practice Address - City:CEIBA
Practice Address - State:PR
Practice Address - Zip Code:00735-2706
Practice Address - Country:US
Practice Address - Phone:787-885-3525
Practice Address - Fax:787-885-3525
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5071208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
E31443Medicare UPIN
26580Medicare ID - Type Unspecified
PR0026580Medicare PIN
75085Medicare ID - Type Unspecified