Provider Demographics
NPI:1265596969
Name:AXTON, JON C (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:C
Last Name:AXTON
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 2263
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73101-2263
Mailing Address - Country:US
Mailing Address - Phone:405-942-8545
Mailing Address - Fax:405-947-6854
Practice Address - Street 1:5300 N GRAND BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-5647
Practice Address - Country:US
Practice Address - Phone:405-942-8545
Practice Address - Fax:405-947-6854
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10228208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100110970AMedicaid
OK$$$$$$$$$002OtherBCBS
OK$$$$$$$$$002OtherBCBS
OK242710703Medicare PIN
OK5390430006Medicare NSC
OK100110970AMedicaid