Provider Demographics
NPI:1316097744
Name:VELARDE, ROBERT PHILLIP (PT)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:PHILLIP
Last Name:VELARDE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6128 VIA CORTA DEL SUR NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-5014
Mailing Address - Country:US
Mailing Address - Phone:505-899-3532
Mailing Address - Fax:
Practice Address - Street 1:401 N 2ND ST
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2507
Practice Address - Country:US
Practice Address - Phone:505-285-2614
Practice Address - Fax:505-287-8487
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2744225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM43637850Medicaid