Provider Demographics
NPI:1215902200
Name:JOHN, MINI (OD)
Entity type:Individual
Prefix:DR
First Name:MINI
Middle Name:
Last Name:JOHN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3102 LONGHORN CIRCLE
Mailing Address - Street 2:
Mailing Address - City:MANVEL
Mailing Address - State:TX
Mailing Address - Zip Code:77578
Mailing Address - Country:US
Mailing Address - Phone:281-300-2109
Mailing Address - Fax:
Practice Address - Street 1:2755 TEXAS PKWY STE 104
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77489-5114
Practice Address - Country:US
Practice Address - Phone:281-416-7077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX06184TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160423302Medicaid
TX11616008OtherCAQH
TX160423302Medicaid
TXTXB110024Medicare PIN
TX11616008OtherCAQH
TXU96011Medicare UPIN