Provider Demographics
NPI:1780975177
Name:MINTZ, JESSICA CARLY SOPHIA (DO)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:CARLY SOPHIA
Last Name:MINTZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:28 BIGELOW ST
Mailing Address - Street 2:APT. B
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-2302
Mailing Address - Country:US
Mailing Address - Phone:973-886-8075
Mailing Address - Fax:
Practice Address - Street 1:LAHEY HOSPITAL & MEDICAL CTR
Practice Address - Street 2:41 MALL RD.
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-8460
Practice Address - Fax:781-744-5261
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA258125207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine