Provider Demographics
NPI:1316924095
Name:MINTZ, MICHAEL LEO (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEO
Last Name:MINTZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:948 E BECK LANE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022
Mailing Address - Country:US
Mailing Address - Phone:602-789-6643
Mailing Address - Fax:
Practice Address - Street 1:2000 W BETHANY HOME RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85019
Practice Address - Country:US
Practice Address - Phone:602-249-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2719207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ156788Medicaid
F48072Medicare UPIN
AZ156788Medicaid