Provider Demographics
NPI:1376828178
Name:MAXINE MINTO MD P.A.
Entity Type:Organization
Organization Name:MAXINE MINTO MD P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAXINE
Authorized Official - Middle Name:JOAN
Authorized Official - Last Name:MINTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-536-5375
Mailing Address - Street 1:10524 MOSS PARK RD
Mailing Address - Street 2:SUITE 204-516
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832-5898
Mailing Address - Country:US
Mailing Address - Phone:407-536-5375
Mailing Address - Fax:407-536-5301
Practice Address - Street 1:1540 INTERNATIONAL PKWY
Practice Address - Street 2:SUITE 2000
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-4713
Practice Address - Country:US
Practice Address - Phone:407-536-5375
Practice Address - Fax:407-536-5301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-12
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69898261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health