Provider Demographics
NPI:1861521551
Name:VELAZQUEZ, MANUEL (MD, PC)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:VELAZQUEZ
Suffix:
Gender:M
Credentials:MD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 61ST ST
Mailing Address - Street 2:APARMENT 5G
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-8550
Mailing Address - Country:US
Mailing Address - Phone:212-353-8314
Mailing Address - Fax:212-353-0567
Practice Address - Street 1:250 E HOUSTON ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-1034
Practice Address - Country:US
Practice Address - Phone:212-353-8314
Practice Address - Fax:212-353-0567
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178165207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01191482Medicaid
NYW0Z561Medicare ID - Type Unspecified
NY01191482Medicaid