Basic Information
| Provider Information | |||||||||
| NPI: | 1437387479 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASTIDAS PALACIOS | ||||||||
| FirstName: | ALEXANDER | ||||||||
| MiddleName: | ANDRES | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2129 | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797602129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326402401 | ||||||||
| FaxNumber: | 4326404606 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797615001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326402401 | ||||||||
| FaxNumber: | 4326404606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2009 | ||||||||
| LastUpdateDate: | 04/06/2016 | ||||||||
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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 | 207RC0200X | P9805 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 339323301 | 05 | TX | MEDICAID |