Provider Demographics
NPI:1902184633
Name:MINA, SALLY (O D)
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:
Last Name:MINA
Suffix:
Gender:
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8621 OHIO DR STE 100
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-2264
Mailing Address - Country:US
Mailing Address - Phone:469-656-8361
Mailing Address - Fax:972-521-6109
Practice Address - Street 1:8621 OHIO DR STE 100
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-2264
Practice Address - Country:US
Practice Address - Phone:469-656-8361
Practice Address - Fax:972-521-6109
Is Sole Proprietor?:No
Enumeration Date:2011-07-29
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2254152W00000X
TX8802TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8802TGOtherTEXAS BOARD OF OPTOMETRY
MDTA2254OtherMARYLAND LICENSE NUMBER