Provider Demographics
NPI:1669444311
Name:MINTZ, EDWARD LESTER (DPM)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:LESTER
Last Name:MINTZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 GRAND AVE
Mailing Address - Street 2:#1E
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-3530
Mailing Address - Country:US
Mailing Address - Phone:201-894-8431
Mailing Address - Fax:202-889-6021
Practice Address - Street 1:81 GRAND AVE
Practice Address - Street 2:#1E
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-3530
Practice Address - Country:US
Practice Address - Phone:201-894-8431
Practice Address - Fax:202-889-6021
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004263-1213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01032291Medicaid
NYU34502Medicare UPIN
NY01032291Medicaid