Provider Demographics
NPI:1598029704
Name:VELASCO, JOHN PAUL (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN PAUL
Middle Name:
Last Name:VELASCO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602658
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2658
Mailing Address - Country:US
Mailing Address - Phone:336-716-2011
Mailing Address - Fax:
Practice Address - Street 1:4614 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-3520
Practice Address - Country:US
Practice Address - Phone:336-716-3787
Practice Address - Fax:336-716-0222
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-01625207Q00000X, 207R00000X
WI84941207Q00000X
MI4301100843207Q00000X
IL036.174129207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100303555Medicaid