MEDICARE: 20-20 CRYSTAL CLEAR VISION, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	6327TG	TX

General Provider Information

NPI Number	:	1336583822
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	20-20 CRYSTAL CLEAR VISION, P.A.

Provider Business Mailing Address
First Line	:	1706 SW LOOP 410 STE 102
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78227-1676
Country	:	US
Telephone Number	:	210-419-4300
Fax Number	:

Provider Business Practice Location Address
First Line	:	1706 SW LOOP 410 STE 102
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78227-1676
Country	:	US
Telephone Number	:	210-419-4300
Fax Number	:

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. EDWARD BUSTAMANTE
Credential	:	O.D.
Telephone Number	:	210-419-4300

Provider Enumeration Date	:	04/26/2013
Last Update Date	:	04/26/2013

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