Provider Demographics
NPI:1851804777
Name:ESTAFANOS, MINA
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:ESTAFANOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8522 PINE RUN CT
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-6934
Mailing Address - Country:US
Mailing Address - Phone:917-929-7989
Mailing Address - Fax:
Practice Address - Street 1:8522 PINE RUN CT
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-6934
Practice Address - Country:US
Practice Address - Phone:917-929-7989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-14
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNA208G00000X
MD24985183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No183500000XPharmacy Service ProvidersPharmacist