Provider Demographics
NPI:1902096852
Name:MINTZER, JONATHAN PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:PHILIP
Last Name:MINTZER
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:STONY BROOK UNIVERSITY MEDICAL CTR
Mailing Address - Street 2:HSC T-11, ROOM 020
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8111
Mailing Address - Country:US
Mailing Address - Phone:631-444-7653
Mailing Address - Fax:
Practice Address - Street 1:STONY BROOK UNIVERSITY MEDICAL CTR
Practice Address - Street 2:HSC T-11, ROOM 020
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8111
Practice Address - Country:US
Practice Address - Phone:631-444-7653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2406852080N0001X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics