Provider Demographics
NPI:1568461986
Name:CAVAZOS, EDMUND III (MD)
Entity Type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:
Last Name:CAVAZOS
Suffix:III
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 897
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-0897
Mailing Address - Country:US
Mailing Address - Phone:270-783-4070
Mailing Address - Fax:270-783-4070
Practice Address - Street 1:4242 MEDICAL DR STE 6300
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5606
Practice Address - Country:US
Practice Address - Phone:210-614-8400
Practice Address - Fax:210-614-8165
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY306392084P0800X, 2084P0800X
TXJ50842084P0800X, 207QG0300X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64306392Medicaid