Provider Demographics
NPI:1205832375
Name:EXTEN, ROBERT EDWIN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EDWIN
Last Name:EXTEN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-1501
Mailing Address - Country:US
Mailing Address - Phone:419-756-2003
Mailing Address - Fax:419-756-3637
Practice Address - Street 1:803 W MARKET ST STE 200
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-2796
Practice Address - Country:US
Practice Address - Phone:419-222-3737
Practice Address - Fax:419-229-3234
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35038459E207RH0003X
OH35.038459207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH830006430OtherMEDICARE RAILRROAD
OH000000142119OtherANTHEM
OH0519460Medicaid
OH000000142119OtherANTHEM
OHWO9307241Medicare ID - Type Unspecified