Provider Demographics
NPI:1609934785
Name:MINTZ, NORMAN JAY (OD)
Entity type:Individual
Prefix:DR
First Name:NORMAN
Middle Name:JAY
Last Name:MINTZ
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 1:825 GRAVENSTEIN HWY N
Mailing Address - Street 2:STE 7
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-2844
Mailing Address - Country:US
Mailing Address - Phone:707-823-9141
Mailing Address - Fax:707-823-5148
Practice Address - Street 1:825 GRAVENSTEIN HWY N
Practice Address - Street 2:STE 7
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-2844
Practice Address - Country:US
Practice Address - Phone:707-823-9141
Practice Address - Fax:707-823-5148
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6087T152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0060870Medicaid
CASD0060870Medicare PIN
CAT10228Medicare UPIN