Provider Demographics
NPI:1811970650
Name:MINNIE, NICKOLAS A (DPM)
Entity type:Individual
Prefix:DR
First Name:NICKOLAS
Middle Name:A
Last Name:MINNIE
Suffix:
Gender:
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9400 S CICERO AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2536
Mailing Address - Country:US
Mailing Address - Phone:708-424-3201
Mailing Address - Fax:708-424-5001
Practice Address - Street 1:3035 HAMILTON MASON RD
Practice Address - Street 2:SUITE 105
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011
Practice Address - Country:US
Practice Address - Phone:513-844-8585
Practice Address - Fax:513-844-8769
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2025-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002464M213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0795359Medicaid
OHT14851Medicare UPIN
OH0795359Medicaid
480024912Medicare PIN
0698420017Medicare NSC
0698420009Medicare NSC