Provider Demographics
NPI:1902184633
Name:MINA, SALLY SAFWAT MIKHAIL (O D)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:SAFWAT MIKHAIL
Last Name:MINA
Suffix:
Gender:F
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 HUNTINGTON LN
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75002-5817
Mailing Address - Country:US
Mailing Address - Phone:469-656-8361
Mailing Address - Fax:
Practice Address - Street 1:613 HUNTINGTON LN
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75002-5817
Practice Address - Country:US
Practice Address - Phone:469-656-8361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-29
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2254152W00000X
TX8802152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDTA2254OtherMARYLAND LICENSE NUMBER