Provider Demographics
NPI:1730180407
Name:AXONOVITZ, ROBERT G (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:AXONOVITZ
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 1:7640 SYLVANIA AVE
Mailing Address - Street 2:I
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-9729
Mailing Address - Country:US
Mailing Address - Phone:419-517-4000
Mailing Address - Fax:419-517-4001
Practice Address - Street 1:7640 SYLVANIA AVE
Practice Address - Street 2:I
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-9729
Practice Address - Country:US
Practice Address - Phone:419-517-4000
Practice Address - Fax:419-517-4001
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35048851A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0540543Medicaid
OH000000130367OtherANTHEM BCBS
OH4119606OtherAETNA
OH795718OtherUNITED HEALTH CARE
OH01059OtherPARAMOUNT
OH795718OtherUNITED HEALTH CARE
OH0540543Medicaid