Healthcare Provider Details

I. General information

NPI: 1154318194
Provider Name (Legal Business Name): TOM MITROS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 N WALNUT ST
BOYERTOWN PA
19512-1467
US

IV. Provider business mailing address

68 S SERVICE RD SUITE 350
MELVILLE NY
11747-2354
US

V. Phone/Fax

Practice location:
  • Phone: 610-367-8844
  • Fax:
Mailing address:
  • Phone: 516-945-3347
  • Fax: 516-945-3131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberCI006035
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberC1-0006035
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA06549800
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD025772E
License Number StatePA
# 5
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD025772E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: