Provider Demographics
NPI:1225798044
Name:MASTERMIND HEALTHCARE, LLC
Entity Type:Organization
Organization Name:MASTERMIND HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:EZINNE
Authorized Official - Middle Name:U
Authorized Official - Last Name:NWOTITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-748-4199
Mailing Address - Street 1:PO BOX 161
Mailing Address - Street 2:
Mailing Address - City:LINWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08221-0161
Mailing Address - Country:US
Mailing Address - Phone:609-365-8120
Mailing Address - Fax:609-365-8207
Practice Address - Street 1:1925 PACIFIC AVE
Practice Address - Street 2:WELLNESS PAVILLION 5TH FLOOR
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401
Practice Address - Country:US
Practice Address - Phone:609-910-4500
Practice Address - Fax:732-693-1214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty