Provider Demographics
NPI:1114126869
Name:MINTALUCCI, DOMINIC J (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:J
Last Name:MINTALUCCI
Suffix:
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 1:1405 MONTGOMERY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4557
Mailing Address - Country:US
Mailing Address - Phone:707-546-1922
Mailing Address - Fax:707-546-1897
Practice Address - Street 1:1405 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4557
Practice Address - Country:US
Practice Address - Phone:707-546-1922
Practice Address - Fax:707-546-1897
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA126421207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA126421OtherLICENSE
CAA126421OtherLICENSE