Provider Demographics
NPI:1679566129
Name:MINGRONE, MARK VINCENT (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:VINCENT
Last Name:MINGRONE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12930 SARATOGA AVE
Mailing Address - Street 2:SUITE B-2
Mailing Address - City:SARATOGA
Mailing Address - State:CA
Mailing Address - Zip Code:95070-4600
Mailing Address - Country:US
Mailing Address - Phone:408-255-2020
Mailing Address - Fax:408-255-2021
Practice Address - Street 1:12930 SARATOGA AVE
Practice Address - Street 2:SUITE B-2
Practice Address - City:SARATOGA
Practice Address - State:CA
Practice Address - Zip Code:95070-4600
Practice Address - Country:US
Practice Address - Phone:408-255-2020
Practice Address - Fax:408-255-2021
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8284T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T10670Medicare UPIN
CA0308000001Medicare NSC