Provider Demographics
NPI:1427165497
Name:BUSTAMANTE, EDWARD (OD,MBA)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:BUSTAMANTE
Suffix:
Gender:M
Credentials:OD,MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10004 WURZBACH RD
Mailing Address - Street 2:352
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-2214
Mailing Address - Country:US
Mailing Address - Phone:210-419-4300
Mailing Address - Fax:
Practice Address - Street 1:310 VALLEY HIGH DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78227-1676
Practice Address - Country:US
Practice Address - Phone:210-419-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX06327TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU94225Medicare UPIN