Provider Demographics
NPI:1578623013
Name:MINARDI, JOHN CHRISTOPHER (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHRISTOPHER
Last Name:MINARDI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:10810 CONNECTICUT AVE
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-2138
Practice Address - Country:US
Practice Address - Phone:301-929-7434
Practice Address - Fax:301-929-7024
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000579152W00000X
DCOP577152W00000X
MDTA1030152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
008535M92Medicare ID - Type Unspecified
U67457Medicare UPIN