Basic Information
| Provider Information | |||||||||
| NPI: | 1003834904 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASFORD | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | WALTON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALTON | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | RHEA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6565 FANNIN ST | ||||||||
| Address2: | FONDREN 270 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134410006 | ||||||||
| FaxNumber: | 7137902797 | ||||||||
| Practice Location | |||||||||
| Address1: | 6565 FANNIN ST | ||||||||
| Address2: | FONDREN 270 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134410006 | ||||||||
| FaxNumber: | 7137902797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 09/29/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | M1496 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207R00000X | M1496 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 184374004 | 05 | TX | MEDICAID | P00947183 | 01 | TX | MEDICARE RR | OTHER | TXB110289 | 01 | MEDICARE PTAN | OTHER | 094010801 | 05 | TX | MEDICAID | 1003834904 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 184374001 | 05 | TX | MEDICAID |