Provider Demographics
NPI:1649299769
Name:CASSANDRA M CAVAZOS
Entity type:Organization
Organization Name:CASSANDRA M CAVAZOS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CAVAZOS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:210-682-4300
Mailing Address - Street 1:5720 BANDERA RD
Mailing Address - Street 2:STE 6
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78238-1985
Mailing Address - Country:US
Mailing Address - Phone:210-682-4300
Mailing Address - Fax:210-682-5838
Practice Address - Street 1:5720 BANDERA RD
Practice Address - Street 2:STE 6
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78238-1985
Practice Address - Country:US
Practice Address - Phone:210-682-4300
Practice Address - Fax:210-682-5838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5559TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU76474Medicare UPIN
TX00W002Medicare ID - Type UnspecifiedGROUP NUMBER