MEDICARE: DR. EDMUND CAVAZOS III M.D.

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	2084P0800X	Psychiatry Physician	30639	KY
2	2084P0800X	Psychiatry Physician	J5084	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568461986
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDMUND CAVAZOS III M.D.

Provider Business Mailing Address
First Line	:	PO BOX 897
Second Line	:
City	:	BOWLING GREEN
State	:	KY
Zip	:	42102-0897
Country	:	US
Telephone Number	:	270-783-4070
Fax Number	:	270-783-4070

Provider Business Practice Location Address
First Line	:	4242 MEDICAL DR STE 6300
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-5606
Country	:	US
Telephone Number	:	210-614-8400
Fax Number	:	210-614-8165

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	02/06/2019

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