Healthcare Provider Details

I. General information

NPI: 1194703629
Provider Name (Legal Business Name): THOMAS M MEXTORF D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 NOLL DR STE 2000
LANCASTER PA
17603-7614
US

IV. Provider business mailing address

2221 NOLL DR STE 2000
LANCASTER PA
17603-7610
US

V. Phone/Fax

Practice location:
  • Phone: 717-715-1001
  • Fax: 717-431-2321
Mailing address:
  • Phone: 717-715-1001
  • Fax: 717-431-2321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS006227L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: