Provider Demographics
NPI:1538167374
Name:AXLINE, BRADLEY P (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:P
Last Name:AXLINE
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:P.O. BOX 271125
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028
Mailing Address - Country:US
Mailing Address - Phone:972-538-2100
Mailing Address - Fax:972-539-2231
Practice Address - Street 1:2560 CENTRAL PARK AVE.
Practice Address - Street 2:#340
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028
Practice Address - Country:US
Practice Address - Phone:972-538-2100
Practice Address - Fax:972-539-2231
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8198207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX118077004Medicaid
TX8BJ298OtherBCBS
TX118077004Medicaid