Healthcare Provider Details

I. General information

NPI: 1194752352
Provider Name (Legal Business Name): EVAN MINTZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 E SHORE RD SUITE 104
GREAT NECK NY
11023-2432
US

IV. Provider business mailing address

310 E SHORE RD SUITE 104
GREAT NECK NY
11023-2432
US

V. Phone/Fax

Practice location:
  • Phone: 516-829-9550
  • Fax: 516-829-9718
Mailing address:
  • Phone: 516-829-9550
  • Fax: 516-829-9718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number177586
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number177586
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: