Provider Demographics
NPI:1366490757
Name:AXELROD, BENNETT J (MD)
Entity Type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:J
Last Name:AXELROD
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4055 JOHNS CREEK PKWY
Mailing Address - Street 2:STE. A
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-1299
Mailing Address - Country:US
Mailing Address - Phone:678-957-3040
Mailing Address - Fax:678-957-3047
Practice Address - Street 1:500 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-8708
Practice Address - Country:US
Practice Address - Phone:770-682-6000
Practice Address - Fax:770-513-1103
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2023-03-07
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Provider Licenses
StateLicense IDTaxonomies
GA026442207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00335926BMedicaid
GAAA703456OtherDEA
GAAA703456OtherDEA