Basic Information
| Provider Information | |||||||||
| NPI: | 1568461986 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAVAZOS | ||||||||
| FirstName: | EDMUND | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 897 | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421020897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707834070 | ||||||||
| FaxNumber: | 2707834070 | ||||||||
| Practice Location | |||||||||
| Address1: | 4242 MEDICAL DR STE 6300 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782295606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106148400 | ||||||||
| FaxNumber: | 2106148165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 02/06/2019 | ||||||||
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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 | 2084P0800X | 30639 | KY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | J5084 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 64306392 | 05 | KY | MEDICAID |