MEDICARE: MARK VINCENT MINGRONE OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	8284T	CA

General Provider Information

NPI Number	:	1679566129
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK VINCENT MINGRONE OD

Provider Business Mailing Address
First Line	:	12930 SARATOGA AVE
Second Line	:	SUITE B-2
City	:	SARATOGA
State	:	CA
Zip	:	95070-4600
Country	:	US
Telephone Number	:	408-255-2020
Fax Number	:	408-255-2021

Provider Business Practice Location Address
First Line	:	12930 SARATOGA AVE
Second Line	:	SUITE B-2
City	:	SARATOGA
State	:	CA
Zip	:	95070-4600
Country	:	US
Telephone Number	:	408-255-2020
Fax Number	:	408-255-2021

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2005
Last Update Date	:	02/13/2008

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