Healthcare Provider Details

I. General information

NPI: 1699725291
Provider Name (Legal Business Name): JOEL AXELROD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 W OLYMPIC BLVD
LOS ANGELES CA
90015-1329
US

IV. Provider business mailing address

1201 WINSTON AVE
SAN MARINO CA
91108-2135
US

V. Phone/Fax

Practice location:
  • Phone: 213-623-2225
  • Fax: 213-861-5859
Mailing address:
  • Phone: 626-396-8242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA10447
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: