Provider Demographics
NPI:1346215787
Name:MINCHOW-PROFFITT, SANDRA K (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:K
Last Name:MINCHOW-PROFFITT
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 1:103 N TAYLOR AVE, STE C
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-4360
Mailing Address - Country:US
Mailing Address - Phone:314-380-4566
Mailing Address - Fax:314-743-3700
Practice Address - Street 1:103 N TAYLOR AVE, STE C
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-4360
Practice Address - Country:US
Practice Address - Phone:314-380-4566
Practice Address - Fax:314-743-3700
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004008255207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00179906OtherRAILROAD MEDICARE
MO1346215787Medicaid
MO1346215787Medicaid
I23921Medicare UPIN