Healthcare Provider Details

I. General information

NPI: 1871541854
Provider Name (Legal Business Name): DAVID L MINTZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MAIN STREET THE AUSTEN RIGGS CENTER
STOCKBRIDGE MA
01262
US

IV. Provider business mailing address

PO BOX 962
STOCKBRIDGE MA
01262-0962
US

V. Phone/Fax

Practice location:
  • Phone: 413-931-5315
  • Fax:
Mailing address:
  • Phone: 413-931-5315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number81082
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: