Provider Demographics
NPI:1114486115
Name:MINNETTE, MATTHEW CARROLL (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CARROLL
Last Name:MINNETTE
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 1:1465 S. GRAND BLVD.
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104
Mailing Address - Country:US
Mailing Address - Phone:314-268-4070
Mailing Address - Fax:314-268-4019
Practice Address - Street 1:1465 S. GRAND BLVD.
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104
Practice Address - Country:US
Practice Address - Phone:314-268-4070
Practice Address - Fax:314-268-4019
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036160247208000000X
390200000X
MO2022004027208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program