Healthcare Provider Details

I. General information

NPI: 1316654049
Provider Name (Legal Business Name): JOHN EDWARD MEDIATORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2022
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 STOVER DR
DELAWARE OH
43015-8601
US

IV. Provider business mailing address

106 STARRET ST STE 100
LANCASTER OH
43130-3993
US

V. Phone/Fax

Practice location:
  • Phone: 740-417-9265
  • Fax:
Mailing address:
  • Phone: 740-687-0042
  • Fax: 740-687-6677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: