Provider Demographics
NPI:1548482771
Name:AXTELL, RICKY J (MD)
Entity type:Individual
Prefix:DR
First Name:RICKY
Middle Name:J
Last Name:AXTELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-375-0862
Mailing Address - Fax:
Practice Address - Street 1:3277 E. LOUISE DR., STE. 200
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-468-5910
Practice Address - Fax:208-884-2979
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-10997207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine