Provider Demographics
NPI:1790745032
Name:JOHN, MINNIE (MD)
Entity Type:Individual
Prefix:DR
First Name:MINNIE
Middle Name:
Last Name:JOHN
Suffix:
Gender:F
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 5444
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-5444
Mailing Address - Country:US
Mailing Address - Phone:718-780-5260
Mailing Address - Fax:718-780-3266
Practice Address - Street 1:263 7TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-7247
Practice Address - Country:US
Practice Address - Phone:718-780-5260
Practice Address - Fax:718-780-3266
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223528208000000X, 2080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02586969Medicaid
I11916Medicare UPIN
NY02586969Medicaid