Provider Demographics
NPI: | 1659466738 |
---|---|
Name: | BOMBACH, EDWARD J (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | EDWARD |
Middle Name: | J |
Last Name: | BOMBACH |
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: | 6210 E HWY 290 |
Mailing Address - Street 2: | |
Mailing Address - City: | AUSTIN |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 78723-1142 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 512-483-9596 |
Mailing Address - Fax: | 512-406-6216 |
Practice Address - Street 1: | 1401 MEDICAL PKWY |
Practice Address - Street 2: | BLDG B #220 |
Practice Address - City: | CEDAR PARK |
Practice Address - State: | TX |
Practice Address - Zip Code: | 78613-7763 |
Practice Address - Country: | US |
Practice Address - Phone: | 512-260-1581 |
Practice Address - Fax: | 512-528-7925 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-10-04 |
Last Update Date: | 2022-04-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NM | 87208 | 208600000X |
TX | F9218 | 208600000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208600000X | Allopathic & Osteopathic Physicians | Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NM | 39859 | Medicaid | |
TX | 188686302 | Medicaid | |
TX | 188686301 | Medicaid | |
C97426 | Medicare UPIN | ||
TX | 188686302 | Medicaid | |
TX | 188686301 | Medicaid | |
349325904 | Medicare PIN | ||
TX | P01022970 | Medicare PIN |