Provider Demographics
NPI:1669480927
Name:MINTZ, IRA R (MO)
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:R
Last Name:MINTZ
Suffix:
Gender:M
Credentials:MO
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 240086
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-9186
Mailing Address - Country:US
Mailing Address - Phone:310-445-2800
Mailing Address - Fax:
Practice Address - Street 1:1516 COTNER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3303
Practice Address - Country:US
Practice Address - Phone:310-445-2800
Practice Address - Fax:310-479-1459
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG290852085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G290850OtherBLUE SHIELD
CA00G290850Medicaid
CAWG29085NMedicare PIN
CA00G290850Medicaid
CAWG29085YMedicare PIN
CAWG29085PMedicare PIN
CAWG29085VMedicare PIN
CAA43951Medicare UPIN
CAWG29085OMedicare PIN
CAWG29085QMedicare PIN
CAWG29085LMedicare PIN
CA00G290850OtherBLUE SHIELD
CAWG29085UMedicare PIN
CAWG29085MMedicare PIN
CAWG29085WMedicare PIN
CAWG29085JMedicare PIN