Provider Demographics
NPI:1669586251
Name:MINECK, COREY (MD)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:MINECK
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:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1601 NW 114TH ST
Practice Address - Street 2:SUITE 230
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-7007
Practice Address - Country:US
Practice Address - Phone:515-222-7761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA35983207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0459941Medicaid
IA0459941Medicaid
IAI15079Medicare ID - Type Unspecified