Healthcare Provider Details

I. General information

NPI: 1366904732
Provider Name (Legal Business Name): MINTU MARY JOHN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 10/17/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1814 WESTCHESTER DR STE 301
HIGH POINT NC
27262-7369
US

IV. Provider business mailing address

100 KIMEL FOREST DR
WINSTON SALEM NC
27103-6074
US

V. Phone/Fax

Practice location:
  • Phone: 413-447-2839
  • Fax: 413-447-2088
Mailing address:
  • Phone: 336-716-1331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2022-002450
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: