Provider Demographics
NPI:1417905225
Name:AXTHELM, DAN ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAN
Middle Name:ALAN
Last Name:AXTHELM
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 1:7100 OAKMONT BLVD
Mailing Address - Street 2:STE 107
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-3911
Mailing Address - Country:US
Mailing Address - Phone:817-764-1894
Mailing Address - Fax:817-346-7545
Practice Address - Street 1:7100 OAKMONT BLVD
Practice Address - Street 2:STE 107
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3911
Practice Address - Country:US
Practice Address - Phone:817-764-1894
Practice Address - Fax:817-346-7545
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3439207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPOOD7434Medicaid
TXPOOD7434Medicaid
OOD743Medicare ID - Type Unspecified