Provider Demographics
NPI:1376617274
Name:BASHAM, BRIAN E (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:E
Last Name:BASHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 DONIPHAN DR
Mailing Address - Street 2:
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850-9120
Mailing Address - Country:US
Mailing Address - Phone:417-451-9450
Mailing Address - Fax:417-451-8903
Practice Address - Street 1:4016 MAIN ST
Practice Address - Street 2:
Practice Address - City:CASSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65625-9753
Practice Address - Country:US
Practice Address - Phone:417-847-0057
Practice Address - Fax:417-847-0079
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7P13207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203173505Medicaid
MO203173505Medicaid
MO293013268Medicare PIN
MO011013230Medicare PIN