Basic Information
| Provider Information | |||||||||
| NPI: | 1649258450 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MINTZ | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 LAUREL OAK RD | ||||||||
| Address2: | SUITE E-2 | ||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080433506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563460005 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1001 LAUREL OAK RD | ||||||||
| Address2: | SUITE E-2 | ||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080433506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563460005 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2006 | ||||||||
| LastUpdateDate: | 12/24/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0402X | 25MA04721900 | NJ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2084P0005X | 25MA04721900 | NJ | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurodevelopmental Disabilities |
No ID Information.