Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NI0013X | Independent Medical Examiner | DC36070 | CA |
NPI | 1134890411 |
---|---|
Provider Name | Michael Anthony Velasco |
First Address | Costa Mesa, CA 92626-4650 |
Second Address | Costa Mesa, CA 92626-4650 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/09/2021 |
Last Update Date | 25/09/2021 |