Healthcare Provider Details

I. General information

NPI: 1083634794
Provider Name (Legal Business Name): CARLOS BAZAN III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 MEDICAL DR
SAN ANTONIO TX
78229-4402
US

IV. Provider business mailing address

310 TAMWORTH DR
SAN ANTONIO TX
78213-1941
US

V. Phone/Fax

Practice location:
  • Phone: 210-450-6470
  • Fax:
Mailing address:
  • Phone: 210-265-8856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberF2547
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberF2547
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: