Provider Demographics
NPI:1164595427
Name:AXLEY, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:AXLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 BAYOU BLVD STE 43
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-1910
Mailing Address - Country:US
Mailing Address - Phone:850-477-3015
Mailing Address - Fax:850-477-3026
Practice Address - Street 1:4400 BAYOU BLVD STE 43
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-1910
Practice Address - Country:US
Practice Address - Phone:850-477-3015
Practice Address - Fax:850-477-3026
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME202372084N0400X
AL000070522084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009945805Medicaid
FL052598700Medicaid
406132045OtherRRB PTAN
FL17275ZMedicare PIN
FL052598700Medicaid