Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 04-37190 | KS |
N | 111NI0900X | Internist | 04-37190 | KS |
N | 207RH0000X | Hematologist | 04-37190 | KS |
N | 207RH0002X | Hospice and Palliative Medicine | 04-37190 | KS |
Y | 207RX0202X | Medical Oncology | 04-37190 | KS |
NPI | 1376731968 |
---|---|
Provider Name | Jose Carlos Velasco Di Domenico |
First Address | Salina, KS 67401-3713 |
Second Address | Liberal, KS 67901-2455 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/10/2007 |
Last Update Date | 12/01/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
16701016 | MEDICARE (01) | KS |
200587760A | (05) | OK |
201099520A | (05) | KS |
201099520B | (05) | KS |
KA3434005 | MEDICARE (01) | KS |