Healthcare Provider Details

I. General information

NPI: 1184641714
Provider Name (Legal Business Name): RICHARD I MINTZ DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7622 OGONTZ AVE
PHILADELPHIA PA
19150-1817
US

IV. Provider business mailing address

7622 OGONTZ AVE
PHILADELPHIA PA
19150-1817
US

V. Phone/Fax

Practice location:
  • Phone: 215-224-8980
  • Fax: 215-224-9342
Mailing address:
  • Phone: 215-224-8980
  • Fax: 215-224-9342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0S003583L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0S003583L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number25MB05998400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: