Provider Demographics
NPI:1194759530
Name:MINTZ, FREDRIC J (MD)
Entity type:Individual
Prefix:DR
First Name:FREDRIC
Middle Name:J
Last Name:MINTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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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
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2008-02-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY150334207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY054AM38471Medicare PIN
NY054AM1Medicare PIN
NYB87320Medicare UPIN