Healthcare Provider Details

I. General information

NPI: 1679566129
Provider Name (Legal Business Name): MARK VINCENT MINGRONE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12930 SARATOGA AVE SUITE B-2
SARATOGA CA
95070-4600
US

IV. Provider business mailing address

12930 SARATOGA AVE SUITE B-2
SARATOGA CA
95070-4600
US

V. Phone/Fax

Practice location:
  • Phone: 408-255-2020
  • Fax: 408-255-2021
Mailing address:
  • Phone: 408-255-2020
  • Fax: 408-255-2021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number8284T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: