Provider Demographics
NPI:1366495236
Name:MINTZ, RUDOLPH IVEY (MD)
Entity Type:Individual
Prefix:DR
First Name:RUDOLPH
Middle Name:IVEY
Last Name:MINTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:400 GLENWOOD AVE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501
Mailing Address - Country:US
Mailing Address - Phone:252-527-5500
Mailing Address - Fax:252-527-4875
Practice Address - Street 1:400 GLENWOOD AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501
Practice Address - Country:US
Practice Address - Phone:252-527-5500
Practice Address - Fax:252-527-4875
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC15536207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8953539Medicaid
NC8953539Medicaid
C85585Medicare UPIN