Provider Demographics
NPI:1932107828
Name:MINOTTI, JOHN REGIS (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:REGIS
Last Name:MINOTTI
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 1:801 11TH ST
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-4100
Mailing Address - Country:US
Mailing Address - Phone:707-263-3746
Mailing Address - Fax:
Practice Address - Street 1:801 11TH ST
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-4100
Practice Address - Country:US
Practice Address - Phone:707-263-3746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC39966207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C399660Medicaid
CA060067540OtherRAILROAD MEDICARE
CA00C399660OtherBLUE SHIELD OF CALIFORNIA
CACC675ZMedicare PIN
CA00C399660OtherBLUE SHIELD OF CALIFORNIA
CAF65682Medicare UPIN
CA060067540OtherRAILROAD MEDICARE