Provider Demographics
NPI:1891107140
Name:MIKSIEWICZ CLUGSTON, TORY JANE (MD)
Entity Type:Individual
Prefix:
First Name:TORY
Middle Name:JANE
Last Name:MIKSIEWICZ CLUGSTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TORY
Other - Middle Name:JANE
Other - Last Name:MIKSIEWICZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:484-884-0699
Practice Address - Street 1:850 GOLDEN DR STE 1
Practice Address - Street 2:
Practice Address - City:BLANDON
Practice Address - State:PA
Practice Address - Zip Code:19510-9657
Practice Address - Country:US
Practice Address - Phone:610-944-5555
Practice Address - Fax:610-944-5551
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT206657207Q00000X
PAMD458193207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine