Provider Demographics
NPI:1932102829
Name:MINK, KENNETH R (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:MINK
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 1:3800 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-3380
Mailing Address - Country:US
Mailing Address - Phone:814-833-0399
Mailing Address - Fax:814-833-4999
Practice Address - Street 1:3800 W 12TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-3380
Practice Address - Country:US
Practice Address - Phone:814-833-0399
Practice Address - Fax:814-833-4999
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD054676L207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMI861599Medicare PIN
PAG25811Medicare UPIN