Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | A126421 | CA |
Y | 207XS0106X | Orthopaedic Hand Surgeon | A126421 | CA |
NPI | 1114126869 |
---|---|
Provider Name | Dominic J Mintalucci |
First Address | Santa Rosa, CA 95405-4557 |
Second Address | Santa Rosa, CA 95405-4557 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/07/2007 |
Last Update Date | 04/10/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A126421 | LICENSE (01) | CA |