Provider Demographics
NPI:1508834169
Name:MINTZ, BRUCE LEE (DO)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:LEE
Last Name:MINTZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 95000
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-7550
Mailing Address - Country:US
Mailing Address - Phone:844-362-1735
Mailing Address - Fax:973-290-7495
Practice Address - Street 1:16 POCONO RD
Practice Address - Street 2:SUITE 313
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-2901
Practice Address - Country:US
Practice Address - Phone:973-625-0112
Practice Address - Fax:973-625-0721
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MB04225400207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC03130Medicare UPIN
NJ519826NUYMedicare PIN