Provider Demographics
NPI:1619925971
Name:MINK, JERROLD (MD)
Entity Type:Individual
Prefix:
First Name:JERROLD
Middle Name:
Last Name:MINK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93062-0190
Mailing Address - Country:US
Mailing Address - Phone:805-522-5940
Mailing Address - Fax:805-522-6401
Practice Address - Street 1:8670 WILSHIRE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2930
Practice Address - Country:US
Practice Address - Phone:310-358-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG226912085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G226910Medicaid
WG22691XMedicare ID - Type Unspecified
CA00G226910Medicaid
WG22691YMedicare ID - Type Unspecified
BV240ZMedicare PIN
A41676Medicare UPIN