Provider Demographics
NPI:1629030283
Name:MINTZ, EDWARD GUSTAVO (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:GUSTAVO
Last Name:MINTZ
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 60371
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0371
Mailing Address - Country:US
Mailing Address - Phone:803-806-0080
Mailing Address - Fax:803-356-0668
Practice Address - Street 1:100 PALMETTO PARK BLVD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072
Practice Address - Country:US
Practice Address - Phone:803-806-0080
Practice Address - Fax:803-356-0668
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16570207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC165706Medicaid
SCF224781357Medicare PIN
SC165706Medicaid