Provider Demographics
NPI:1568604668
Name:MINER, ANDREW GLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:GLEN
Last Name:MINER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1272 VESTAVIA CIR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-2301
Mailing Address - Country:US
Mailing Address - Phone:786-877-2831
Mailing Address - Fax:
Practice Address - Street 1:1286 FLORIDA AVE S
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2484
Practice Address - Country:US
Practice Address - Phone:321-636-7780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-03
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.122891207N00000X
FLME118731207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHT739ZOtherMEDICARE PTAN