Provider Demographics
NPI:1831266154
Name:BASTYR, EDWARD J III (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:J
Last Name:BASTYR
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 1:250 N SHADELAND AVE.
Mailing Address - Street 2:SUITE 130
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-823-9357
Mailing Address - Fax:317-823-9357
Practice Address - Street 1:720 ESKENAZI AVE
Practice Address - Street 2:UNIVERSITY MEDICAL DIAGNOSTIC ASSOCIATES, INC.
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5166
Practice Address - Country:US
Practice Address - Phone:317-880-5045
Practice Address - Fax:317-880-0414
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044193A282N00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201291380Medicaid
IN201291380Medicaid