Basic Information
| Provider Information | |||||||||
| NPI: | 1093990681 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AXELROD | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 VALLEY STREAM PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | MALVERN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193551407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106448900 | ||||||||
| FaxNumber: | 4849240053 | ||||||||
| Practice Location | |||||||||
| Address1: | 17660 UNION TPKE STE 130 | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188209729 | ||||||||
| FaxNumber: | 7188209730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2008 | ||||||||
| LastUpdateDate: | 05/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 225185-1 | NY | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 225185-1 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 02944269 | 05 | NY | MEDICAID |