Provider Demographics
NPI:1194703629
Name:MEXTORF, THOMAS M (DO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:MEXTORF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 NOLL DR
Mailing Address - Street 2:STE 2000
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-7610
Mailing Address - Country:US
Mailing Address - Phone:717-715-1001
Mailing Address - Fax:717-431-2321
Practice Address - Street 1:2221 NOLL DR STE 2000
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603-7614
Practice Address - Country:US
Practice Address - Phone:717-715-1001
Practice Address - Fax:717-431-2321
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006227L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011392930010Medicaid
B41038Medicare UPIN
PA0011392930010Medicaid