Basic Information
| Provider Information | |||||||||
| NPI: | 1225021256 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACARES | ||||||||
| FirstName: | EDGAR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 E UNIVERSITY AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786266821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778005722 | ||||||||
| FaxNumber: | 5122571763 | ||||||||
| Practice Location | |||||||||
| Address1: | 2120 N MAYS ST | ||||||||
| Address2: | |||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786642192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778005722 | ||||||||
| FaxNumber: | 5122571763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 02/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 209528 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | M9827 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 01971448 | 05 | NY | MEDICAID |