Provider Demographics
NPI:1164479127
Name:MINTZ, MARC A (DO)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:A
Last Name:MINTZ
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 1:15925 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90603-2524
Mailing Address - Country:US
Mailing Address - Phone:562-947-8681
Mailing Address - Fax:562-947-4785
Practice Address - Street 1:15925 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90603-2524
Practice Address - Country:US
Practice Address - Phone:562-947-8681
Practice Address - Fax:562-947-4785
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4252174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA93573Medicare UPIN
CAW20A4252AMedicare ID - Type Unspecified