Provider Demographics
NPI:1689680217
Name:MINK, JONATHAN W (MD, PHD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:W
Last Name:MINK
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 278984
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14627-8984
Mailing Address - Country:US
Mailing Address - Phone:585-275-2808
Mailing Address - Fax:585-275-3683
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-275-2808
Practice Address - Fax:585-275-3683
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY2192182084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02283416Medicaid
NY02283416Medicaid