Healthcare Provider Details

I. General information

NPI: 1407859960
Provider Name (Legal Business Name): FREDRIC M MINTZER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1517 DURHAM RD
PENNDEL PA
19047-5707
US

IV. Provider business mailing address

4041 S WARNER RD
LAFAYETTE HILL PA
19444-1421
US

V. Phone/Fax

Practice location:
  • Phone: 215-752-1541
  • Fax: 215-752-7195
Mailing address:
  • Phone: 610-828-4428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD022742E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: