Provider Demographics
NPI:1184710840
Name:MINEVICH, GREGORY A (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:MINEVICH
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 1:1290 B STREET
Mailing Address - Street 2:SUITE 305
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541
Mailing Address - Country:US
Mailing Address - Phone:510-881-5203
Mailing Address - Fax:510-881-5180
Practice Address - Street 1:1290 B ST
Practice Address - Street 2:SUITE 305
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-2948
Practice Address - Country:US
Practice Address - Phone:510-881-5203
Practice Address - Fax:510-881-5180
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0041590Medicaid