Provider Demographics
NPI:1821056615
Name:HERRMANNSDOERFER, AXEL JUERGEN (MD)
Entity Type:Individual
Prefix:
First Name:AXEL
Middle Name:JUERGEN
Last Name:HERRMANNSDOERFER
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:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:518-649-4094
Practice Address - Street 1:1 TALLOW WOOD DR
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-2807
Practice Address - Country:US
Practice Address - Phone:518-373-4444
Practice Address - Fax:518-373-0663
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY202113207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01666242Medicaid
NYBB2432Medicare ID - Type Unspecified
NYBB2432Medicare PIN
NY01666242Medicaid