Provider Demographics
NPI:1437387479
Name:BASTIDAS PALACIOS, ALEXANDER ANDRES (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:ANDRES
Last Name:BASTIDAS PALACIOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2129
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79760-2129
Mailing Address - Country:US
Mailing Address - Phone:432-640-2401
Mailing Address - Fax:432-640-4606
Practice Address - Street 1:500 W 4TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5001
Practice Address - Country:US
Practice Address - Phone:432-640-2401
Practice Address - Fax:432-640-4606
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP9805207RC0200X, 207RC0200X
PAMT 194345207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX339323301Medicaid
TX339323301Medicaid