Provider Demographics
NPI:1447284831
Name:VELASCO, LUIS DAVID (MD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:DAVID
Last Name:VELASCO
Suffix:
Gender:M
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-6901
Mailing Address - Fax:704-384-6902
Practice Address - Street 1:1401 MATTHEWS TOWNSHIP PKWY
Practice Address - Street 2:STE 200
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5402
Practice Address - Country:US
Practice Address - Phone:704-384-6901
Practice Address - Fax:704-384-6902
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31673207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00399299OtherRR MEDICARE
NC110168797OtherRR MEDICARE
NC84899OtherBC BS NC
NC8984899Medicaid
NC1447284831Medicaid
SCN31673Medicaid
NC1447284831Medicaid
NC110168797OtherRR MEDICARE
NCC86908Medicare UPIN
NC8984899Medicaid
SCN31673Medicaid