Healthcare Provider Details

I. General information

NPI: 1932107828
Provider Name (Legal Business Name): JOHN REGIS MINOTTI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 11TH ST
LAKEPORT CA
95453-4100
US

IV. Provider business mailing address

801 11TH ST
LAKEPORT CA
95453-4100
US

V. Phone/Fax

Practice location:
  • Phone: 707-263-3746
  • Fax:
Mailing address:
  • Phone: 707-263-3746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberC39966
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberC39966
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: