Provider Demographics
NPI:1538229323
Name:AXIS MEDICAL GROUP
Entity type:Organization
Organization Name:AXIS MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:LUQUE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:323-268-5060
Mailing Address - Street 1:326 N SOTO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1815
Mailing Address - Country:US
Mailing Address - Phone:323-268-5060
Mailing Address - Fax:323-268-5048
Practice Address - Street 1:326 N SOTO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1815
Practice Address - Country:US
Practice Address - Phone:323-268-5060
Practice Address - Fax:323-268-5048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6453208D00000X
CA20A6465207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0086320Medicaid
CAW14800Medicare ID - Type UnspecifiedMEDICARE I.D. NUMBER