MEDICARE: LOAY KHALID BASUDAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	BP10033178	TX

General Provider Information

NPI Number	:	1144469925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOAY KHALID BASUDAN

Provider Business Mailing Address
First Line	:	2380 S MACGREGOR WAY APT 422
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77021-1174
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2380 S MACGREGOR WAY APT 422
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77021-1174
Country	:	US
Telephone Number	:	281-888-4752
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/18/2009
Last Update Date	:	02/18/2009

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