Provider Demographics
NPI:1902850704
Name:MINER, THOMAS RAY (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:RAY
Last Name:MINER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 ASSOCIATES DR
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-2201
Mailing Address - Country:US
Mailing Address - Phone:563-584-4100
Mailing Address - Fax:563-584-4110
Practice Address - Street 1:1121 3RD ST SW
Practice Address - Street 2:
Practice Address - City:DYERSVILLE
Practice Address - State:IA
Practice Address - Zip Code:52040-1725
Practice Address - Country:US
Practice Address - Phone:563-875-2776
Practice Address - Fax:563-875-7657
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02121207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1091983Medicaid
IAI17189Medicare ID - Type Unspecified
IA1091983Medicaid