MEDICARE: THOMAS M MEXTORF D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	OS006227L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194703629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS M MEXTORF D.O.

Provider Business Mailing Address
First Line	:	2221 NOLL DR
Second Line	:	STE 2000
City	:	LANCASTER
State	:	PA
Zip	:	17603-7610
Country	:	US
Telephone Number	:	717-715-1001
Fax Number	:	717-431-2321

Provider Business Practice Location Address
First Line	:	2221 NOLL DR STE 2000
Second Line	:
City	:	LANCASTER
State	:	PA
Zip	:	17603-7614
Country	:	US
Telephone Number	:	717-715-1001
Fax Number	:	717-431-2321

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2006
Last Update Date	:	10/16/2019

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