Provider Demographics
NPI:1003834904
Name:BASFORD, AMANDA WALTON (MD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:WALTON
Last Name:BASFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AMANDA
Other - Middle Name:RHEA
Other - Last Name:WALTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6565 FANNIN ST
Mailing Address - Street 2:FONDREN 270
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2703
Mailing Address - Country:US
Mailing Address - Phone:713-441-0006
Mailing Address - Fax:713-790-2797
Practice Address - Street 1:6565 FANNIN ST
Practice Address - Street 2:FONDREN 270
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2703
Practice Address - Country:US
Practice Address - Phone:713-441-0006
Practice Address - Fax:713-790-2797
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1496207RN0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184374004Medicaid
TXP00947183OtherMEDICARE RR
TXB110289OtherMEDICARE PTAN
TX094010801Medicaid
TX1003834904OtherBLUE CROSS BLUE SHIELD
TX184374001Medicaid
TX184374001Medicaid
TXTXB119549Medicare PIN
TX00J21AMedicare PIN