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
StateLicense IDTaxonomies
NM87208208600000X
TXF9218208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM39859Medicaid
TX188686302Medicaid
TX188686301Medicaid
C97426Medicare UPIN
TX188686302Medicaid
TX188686301Medicaid
349325904Medicare PIN
TXP01022970Medicare PIN