Provider Demographics
NPI:1598850893
Name:MINTZ FAMILY OPTOMETRY, APC
Entity type:Organization
Organization Name:MINTZ FAMILY OPTOMETRY, APC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MINTZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-985-2876
Mailing Address - Street 1:553 NORTH MOUNTAIN AVENUE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-5016
Mailing Address - Country:US
Mailing Address - Phone:909-985-2876
Mailing Address - Fax:909-946-8585
Practice Address - Street 1:553 NORTH MOUNTAIN AVENUE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-5016
Practice Address - Country:US
Practice Address - Phone:909-985-2876
Practice Address - Fax:909-946-8585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4109T152W00000X
CA5933T152W00000X
CA8810T152W00000X
CAOPT8810TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1871584581OtherNPI FOR INDIVIDUAL RUBIN
CA45941OtherID FOR SAFEGUARD
CA9V12145OtherIEHP ID
CA1417948092OtherNPI INDIVIDUAL FOR MINTZ
CA16110OtherRUBIN ID FOR MES VISION
CA35021OtherGVA ID NUMBER
CA12993OtherID FOR VBA
CA3163OtherMINTZ ID FOR MES VISION
CA49103OtherID FOR SAFEGUARD PPO
CASD0041091Medicaid
CA09160OtherSPECTERA
CA211537OtherEYMED ID
CA091303OtherDELTA VISION ID
CA9V12145OtherIEHP ID
CA211537OtherEYMED ID
CADI932AMedicare PIN