Provider Demographics
NPI:1164675625
Name:MINO, DAVID EDMOND (MD, MBA)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:EDMOND
Last Name:MINO
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 LAFAYETTE DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON CROSSING
Mailing Address - State:PA
Mailing Address - Zip Code:18977-1413
Mailing Address - Country:US
Mailing Address - Phone:215-801-9967
Mailing Address - Fax:
Practice Address - Street 1:103 LAFAYETTE DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON CROSSING
Practice Address - State:PA
Practice Address - Zip Code:18977-1413
Practice Address - Country:US
Practice Address - Phone:215-801-9967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD028775E207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAC34256Medicare UPIN