Provider Demographics
NPI:1154732386
Name:AXIBAL, EILEEN LARKIN (MD)
Entity type:Individual
Prefix:DR
First Name:EILEEN
Middle Name:LARKIN
Last Name:AXIBAL
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1740 E PARIS AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6204
Mailing Address - Country:US
Mailing Address - Phone:616-949-5600
Mailing Address - Fax:616-949-6571
Practice Address - Street 1:1740 E PARIS AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6204
Practice Address - Country:US
Practice Address - Phone:616-949-5600
Practice Address - Fax:616-949-6571
Is Sole Proprietor?:No
Enumeration Date:2014-05-09
Last Update Date:2024-01-10
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Provider Licenses
StateLicense IDTaxonomies
NC2019-00214207ND0101X
SC82323207ND0101X
CO021728207N00000X
MI4301502472207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology