Basic Information
| Provider Information | |||||||||
| NPI: | 1447284831 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VELASCO | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043846901 | ||||||||
| FaxNumber: | 7043846902 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 MATTHEWS TOWNSHIP PKWY | ||||||||
| Address2: | STE 200 | ||||||||
| City: | MATTHEWS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281055402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043846901 | ||||||||
| FaxNumber: | 7043846902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 08/10/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 31673 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00399299 | 01 | NC | RR MEDICARE | OTHER | 110168797 | 01 | NC | RR MEDICARE | OTHER | 84899 | 01 | NC | BC BS NC | OTHER | 8984899 | 05 | NC | MEDICAID | 1447284831 | 05 | NC | MEDICAID | N31673 | 05 | SC | MEDICAID |