MEDICARE: DR. MINI JOHN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	06184TG	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	11616008	OTHER	TX	CAQH

General Provider Information

NPI Number	:	1215902200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MINI JOHN O.D.

Provider Business Mailing Address
First Line	:	3102 LONGHORN CIRCLE
Second Line	:
City	:	MANVEL
State	:	TX
Zip	:	77578
Country	:	US
Telephone Number	:	281-300-2109
Fax Number	:

Provider Business Practice Location Address
First Line	:	2755 TEXAS PKWY STE 104
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77489-5114
Country	:	US
Telephone Number	:	281-416-7077
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2006
Last Update Date	:	01/26/2012

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Directions to “ DR. MINI JOHN O.D.” Practice Location

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