Provider Demographics
NPI:1457534141
Name:FREDRIC J MINTZ, MD, PC
Entity Type:Organization
Organization Name:FREDRIC J MINTZ, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDRIC
Authorized Official - Middle Name:J
Authorized Official - Last Name:MINTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-682-0001
Mailing Address - Street 1:175 JERICHO TPKE
Mailing Address - Street 2:SUITE 217
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-4532
Mailing Address - Country:US
Mailing Address - Phone:516-682-0001
Mailing Address - Fax:516-682-0004
Practice Address - Street 1:175 JERICHO TPKE
Practice Address - Street 2:SUITE 217
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4532
Practice Address - Country:US
Practice Address - Phone:516-682-0001
Practice Address - Fax:516-682-0004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150334207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB87320Medicare UPIN
NYW38471Medicare PIN