Provider Demographics
NPI:1669472320
Name:MINEAU, D EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:D
Middle Name:EDWARD
Last Name:MINEAU
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:PO BOX 1369
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-1369
Mailing Address - Country:US
Mailing Address - Phone:801-296-2113
Mailing Address - Fax:801-296-1715
Practice Address - Street 1:1200 E 3900 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1300
Practice Address - Country:US
Practice Address - Phone:801-268-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT152665-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003812200Medicaid
WY120732600Medicaid
AZ927741Medicaid
NV002087689Medicaid
UT04348Medicaid
UTP00651547OtherRR MEDICARE
WY120732600Medicaid
UTP00199668Medicare PIN
AZ927741Medicaid
UT005783009Medicare PIN