Provider Demographics
NPI:1750655411
Name:FRAUSTO, EDGGAR EMMANUEL (MD)
Entity Type:Individual
Prefix:
First Name:EDGGAR
Middle Name:EMMANUEL
Last Name:FRAUSTO
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 1:2010 E 28TH ST
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78574-2002
Mailing Address - Country:US
Mailing Address - Phone:956-735-8485
Mailing Address - Fax:
Practice Address - Street 1:7703 FLOYD CURL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3901
Practice Address - Country:US
Practice Address - Phone:210-617-5311
Practice Address - Fax:210-949-3060
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-28
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXQ4108207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program