Provider Demographics
NPI:1891784922
Name:MINA, EVA S (MD)
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:S
Last Name:MINA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:479 WESTPARK WAY
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76040-3957
Mailing Address - Country:US
Mailing Address - Phone:817-358-5500
Mailing Address - Fax:817-358-5511
Practice Address - Street 1:3100 NORTH TARRANT PARKWAY #104
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-8616
Practice Address - Country:US
Practice Address - Phone:817-358-5500
Practice Address - Fax:817-358-5511
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8344207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX155961901Medicaid
G01677Medicare UPIN
TX8235N2Medicare ID - Type Unspecified
TX461218YXJGMedicare PIN