Provider Demographics
NPI:1912070293
Name:JOHN AXLEY M D P A
Entity Type:Organization
Organization Name:JOHN AXLEY M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:AXLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-477-3015
Mailing Address - Street 1:4400 BAYOU BLVD STE 43
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-1910
Mailing Address - Country:US
Mailing Address - Phone:850-477-3015
Mailing Address - Fax:850-477-3026
Practice Address - Street 1:4400 BAYOU BLVD STE 43
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-1910
Practice Address - Country:US
Practice Address - Phone:850-477-3015
Practice Address - Fax:850-477-3026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME202372084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE7927OtherRRB PTAN
AL529918810Medicaid
FLD53211Medicare UPIN
AL529918810Medicaid