Provider Demographics
NPI:1457335770
Name:MINA, JOHN W (DPM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:MINA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8851 BOARDROOM CIRCLE
Mailing Address - Street 2:
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-4888
Mailing Address - Country:US
Mailing Address - Phone:239-481-7000
Mailing Address - Fax:239-481-5180
Practice Address - Street 1:8851 BOARDROOM CIRCLE
Practice Address - Street 2:
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-4888
Practice Address - Country:US
Practice Address - Phone:239-481-7000
Practice Address - Fax:239-481-5180
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1386213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1065630001OtherMEDICARE DME
FL480000496AOtherRAILROAD MEDICARE
FL87717ZMedicare PIN
FL1065630001OtherMEDICARE DME
T55514Medicare UPIN
FL480000496AOtherRAILROAD MEDICARE