Provider Demographics
NPI:1215956503
Name:FLETCHER, FLAXIE ROBERSON (MD)
Entity type:Individual
Prefix:DR
First Name:FLAXIE
Middle Name:ROBERSON
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3737 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:SUITE #604
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-3513
Mailing Address - Country:US
Mailing Address - Phone:310-637-1971
Mailing Address - Fax:310-637-1049
Practice Address - Street 1:3737 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE #604
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3513
Practice Address - Country:US
Practice Address - Phone:310-637-1971
Practice Address - Fax:310-637-1049
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC037011174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000C370111Medicaid
CA040003119OtherRAILRAOD MEDICARE
CA040003119OtherRAILRAOD MEDICARE
CAC37011Medicare PIN