Provider Demographics
NPI:1639282833
Name:AXTHELM, STEPHEN C (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:C
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 1:1057 LAKESIDE CT
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-2817
Mailing Address - Country:US
Mailing Address - Phone:970-241-5692
Mailing Address - Fax:
Practice Address - Street 1:1057 LAKESIDE CT
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-2817
Practice Address - Country:US
Practice Address - Phone:970-241-5692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23702208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01237023Medicaid
COD24310Medicare UPIN
CO01237023Medicaid