Provider Demographics
NPI:1275548786
Name:MINETTE, MARY SARA (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SARA
Last Name:MINETTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 SW GAINES ST
Mailing Address - Street 2:PEDIATRIC CARDIOLOGY, CDRC-P
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2901
Mailing Address - Country:US
Mailing Address - Phone:503-494-2192
Mailing Address - Fax:503-494-2824
Practice Address - Street 1:707 SW GAINES ST
Practice Address - Street 2:PEDIATRIC CARDIOLOGY, CDRC-P
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2901
Practice Address - Country:US
Practice Address - Phone:503-494-2192
Practice Address - Fax:503-494-2824
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD197722080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150183Medicaid
OR150183Medicaid