Provider Demographics
NPI:1598747602
Name:AXTMAYER, ALFREDO LUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:ALFREDO
Middle Name:LUIS
Last Name:AXTMAYER
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 1:8 RESEARCH PKWY
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-1929
Mailing Address - Country:US
Mailing Address - Phone:203-265-9122
Mailing Address - Fax:203-265-9159
Practice Address - Street 1:8 RESEARCH PKWY
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-1929
Practice Address - Country:US
Practice Address - Phone:203-265-9122
Practice Address - Fax:203-265-9159
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT022215207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2V3535OtherHEALTHNET ID #
CT004239176Medicaid
CT010022215CT07OtherANTHEM ID #
CT0045604OtherAETNA ID #
CTP1279064OtherOXFORD ID #
CT783182OtherCONNECTICARE ID #
CT200001167Medicare PIN
CT0045604OtherAETNA ID #
CTB84045Medicare UPIN