Provider Demographics
NPI:1053386342
Name:MINTZ, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:MINTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:507 DEL PRADO BOULEVARD
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990
Practice Address - Country:US
Practice Address - Phone:239-772-0500
Practice Address - Fax:239-772-3076
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0031596208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL202216OtherAMERIGROUP PROVIDER NUM.
FL256184OtherUSA MNGD. CR. PROVIDER #
FL709333OtherFIRST HLTH/CCN PROVIDER #
FL1193412OtherWELLCARE
FL1262065-010OtherCIGNA PROVIDER NUMBER
FL4197070OtherAETNA PROVIDER NUMBER
FL79302OtherBCBS PROVIDER NUMBER
FL038588300Medicaid
FL277536OtherAVMED PROVIDER NUMBER
FL68175OtherOP. ENGIN. PROVIDER #
FLME0031596OtherMETCARE PROVIDER NUMBER
FLD67273Medicare UPIN
FL038588300Medicaid