MEDICARE: AXIS MEDICAL GROUP

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	208D00000X	General Practice Physician	20A6453	CA
2	207R00000X	Internal Medicine Physician	20A6465	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538229323
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AXIS MEDICAL GROUP

Provider Business Mailing Address
First Line	:	326 N SOTO ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90033-1815
Country	:	US
Telephone Number	:	323-268-5060
Fax Number	:	323-268-5048

Provider Business Practice Location Address
First Line	:	326 N SOTO ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90033-1815
Country	:	US
Telephone Number	:	323-268-5060
Fax Number	:	323-268-5048

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. HECTOR LUQUE
Credential	:	D.O.
Telephone Number	:	323-268-5060

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	06/12/2008

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Directions to “AXIS MEDICAL GROUP ” Practice Location

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