Provider Demographics
NPI:1841420916
Name:ALLENSWORTH, AMANDA GAYLE (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:GAYLE
Last Name:ALLENSWORTH
Suffix:
Gender:F
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:PO BOX 26726
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-0726
Mailing Address - Country:US
Mailing Address - Phone:512-407-8686
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:4100 EVERETT DR STE 400
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-6147
Practice Address - Country:US
Practice Address - Phone:512-504-5186
Practice Address - Fax:512-504-5536
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP3112207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX303142902Medicaid
TX303142903Medicaid
TX303142901Medicaid
TX303142904Medicaid
TXP01103151Medicare PIN
TXP01173482Medicare PIN
TXTXB159323Medicare PIN
TX303142904Medicaid
TXTXB159329Medicare PIN
TX303142901Medicaid