Healthcare Provider Details

I. General information

NPI: 1205832375
Provider Name (Legal Business Name): ROBERT EDWIN EXTEN JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 W MARKET ST STE 200
LIMA OH
45805-2796
US

IV. Provider business mailing address

475 LEXINGTON AVE
MANSFIELD OH
44907-1501
US

V. Phone/Fax

Practice location:
  • Phone: 419-222-3737
  • Fax: 419-229-3234
Mailing address:
  • Phone: 419-756-2003
  • Fax: 419-756-3637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number35.038459
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number35038459E
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: