Doctor Name: | DR. MATTHEW CHARLES AXTMAN |
NPI Number: | 1255478988 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | DO |
License Number: | 11014234A |
Business Practice Address: | 4100 Lake Dr Se Ste 300 Grand Rapids, MI - 495468292 |
Business Phone Number: | 6162678860 |
Business Fax Number: | 6162678442 |
Mailing Address: | 100 Michigan St Ne, Mc845 GRAND RAPIDS |
State: | MI |
Postal Code: | 495032560 |
Phone Number: | |
Fax Number: | |
NPI Enumeration Date: | 01/31/2007 |
NPI Last Update Date: | 08/08/2013 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 390200000X |
License Number: | 11014234A |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | IN |
Taxonomy Type: | Student, Health Care |
Taxonomy Classification: | Student in an Organized Health Care Education/Training Program |
Taxonomy Specialization: | |
Taxonomy Definition: | An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care. |