Provider Demographics
NPI:1518036979
Name:MINTER, RICHARD EARL (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:EARL
Last Name:MINTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 E GRANT ST STE 202
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3373
Mailing Address - Country:US
Mailing Address - Phone:309-833-1729
Mailing Address - Fax:
Practice Address - Street 1:505 E GRANT ST STE 202
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3373
Practice Address - Country:US
Practice Address - Phone:309-833-1729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4F20207Q00000X, 333600000X
IL036.139552207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.139552OtherLICENSE
MO263857Medicare ID - Type Unspecified
MO598542801Medicaid