Provider Demographics
NPI:1316030521
Name:MANSFIELD DERMATOLOGY INC
Entity Type:Organization
Organization Name:MANSFIELD DERMATOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:MORITZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-756-5739
Mailing Address - Street 1:PO BOX 543
Mailing Address - Street 2:
Mailing Address - City:LEWIS CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43035
Mailing Address - Country:US
Mailing Address - Phone:740-549-2596
Mailing Address - Fax:740-549-0047
Practice Address - Street 1:161 CLINE AVENUE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907
Practice Address - Country:US
Practice Address - Phone:419-756-5739
Practice Address - Fax:419-756-4968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35054857M207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0856720Medicaid
F17719Medicare UPIN
OHM00710352Medicare ID - Type Unspecified