Provider Demographics
NPI:1831174192
Name:AXELSSON, BOERJE A (MD)
Entity type:Individual
Prefix:
First Name:BOERJE
Middle Name:A
Last Name:AXELSSON
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 1:6600 S YALE AVE
Mailing Address - Street 2:STE 1400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3310
Mailing Address - Country:US
Mailing Address - Phone:918-488-6001
Mailing Address - Fax:918-488-6010
Practice Address - Street 1:30011 E STATE HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:COWETA
Practice Address - State:OK
Practice Address - Zip Code:74429-7681
Practice Address - Country:US
Practice Address - Phone:918-486-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13435207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKA28986Medicare UPIN