MEDICARE: DR. MITCHELL MINIX 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	18004109A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	18004109A	OTHER	IN	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1760977193
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MITCHELL MINIX OD

Provider Business Mailing Address
First Line	:	6110 MAPLECREST RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46835-2524
Country	:	US
Telephone Number	:	260-486-8833
Fax Number	:

Provider Business Practice Location Address
First Line	:	6110 MAPLECREST RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46835-2524
Country	:	US
Telephone Number	:	260-486-8833
Fax Number	:

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

Provider Enumeration Date	:	06/27/2018
Last Update Date	:	06/27/2018

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Directions to “ DR. MITCHELL MINIX OD” Practice Location

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