Provider Demographics
NPI:1831150739
Name:MINKOFF, EVAN R (DO)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:R
Last Name:MINKOFF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:EVAN
Other - Middle Name:R
Other - Last Name:MINKOFF
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:72780 COUNTRY CLUB DR
Mailing Address - Street 2:SUITE C 300
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-4126
Mailing Address - Country:US
Mailing Address - Phone:760-341-5550
Mailing Address - Fax:760-341-6050
Practice Address - Street 1:72780 COUNTRY CLUB DR
Practice Address - Street 2:SUITE C 300
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4126
Practice Address - Country:US
Practice Address - Phone:760-341-5550
Practice Address - Fax:760-341-5550
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2011-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A77842081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020A77841Medicare PIN
CAH95523Medicare UPIN