Provider Demographics
NPI:1376165357
Name:MINA, REBECCA RIAD (DPM)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:RIAD
Last Name:MINA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 MAPLE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:WOODBURY HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:08097-1128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19 MAPLE AVE STE A
Practice Address - Street 2:
Practice Address - City:WOODBURY HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:08097-1128
Practice Address - Country:US
Practice Address - Phone:856-384-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00377100213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery