Provider Demographics
NPI:1437422292
Name:STANTON G. AXLINE M.D. A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:STANTON G. AXLINE M.D. A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STANTON
Authorized Official - Middle Name:G
Authorized Official - Last Name:AXLINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-829-0912
Mailing Address - Street 1:2001 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 655W
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2102
Mailing Address - Country:US
Mailing Address - Phone:310-829-0919
Mailing Address - Fax:310-829-1260
Practice Address - Street 1:2001 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 655W
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2102
Practice Address - Country:US
Practice Address - Phone:310-829-0919
Practice Address - Fax:310-829-1260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-09
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC23954207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty