Basic Information
| Provider Information | |||||||||
| NPI: | 1780975177 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MINTZ | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | CARLY SOPHIA | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28 BIGELOW ST | ||||||||
| Address2: | APT. B | ||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021392302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738868075 | ||||||||
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| Practice Location | |||||||||
| Address1: | LAHEY HOSPITAL & MEDICAL CTR | ||||||||
| Address2: | 41 MALL RD. | ||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018050001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817448460 | ||||||||
| FaxNumber: | 7817445261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2011 | ||||||||
| LastUpdateDate: | 07/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 258125 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 258125 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.