Healthcare Provider Details

I. General information

NPI: 1992239354
Provider Name (Legal Business Name): MEHWISH MOINUDDIN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2017
Last Update Date: 07/23/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 HOSPITAL DRIVE STE 112
STATE COLLEGE PA
16803-6706
US

IV. Provider business mailing address

500 UNIVERSITY DR MC CA410
HERSHEY PA
17033-2360
US

V. Phone/Fax

Practice location:
  • Phone: 800-243-1455
  • Fax: 814-863-7803
Mailing address:
  • Phone: 800-243-1455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS022254
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: