Provider Demographics
NPI:1891897997
Name:MINNICK, DAVID A (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:MINNICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 690
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:NE
Mailing Address - Zip Code:68822
Mailing Address - Country:US
Mailing Address - Phone:308-872-2486
Mailing Address - Fax:308-872-2027
Practice Address - Street 1:145 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:NE
Practice Address - Zip Code:68822
Practice Address - Country:US
Practice Address - Phone:308-872-2486
Practice Address - Fax:308-872-2027
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE19206207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F65085Medicare UPIN
NE265401MIMedicare PIN