Provider Demographics
NPI:1871225847
Name:UNTALAN, AXLE MARIA RAFAELLE DIMAYUGA (MD)
Entity Type:Individual
Prefix:DR
First Name:AXLE MARIA RAFAELLE
Middle Name:DIMAYUGA
Last Name:UNTALAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SAIRS AVE APT 18
Mailing Address - Street 2:
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740-5628
Mailing Address - Country:US
Mailing Address - Phone:917-656-7637
Mailing Address - Fax:
Practice Address - Street 1:300 2ND AVE
Practice Address - Street 2:
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6303
Practice Address - Country:US
Practice Address - Phone:732-923-6537
Practice Address - Fax:732-923-6536
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program