Healthcare Provider Details

I. General information

NPI: 1205462108
Provider Name (Legal Business Name): MICHAEL MIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25845 BARTON RD
LOMA LINDA CA
92354-3899
US

IV. Provider business mailing address

11175 CAMPUS ST RM A1111
LOMA LINDA CA
92350-1700
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-2828
  • Fax:
Mailing address:
  • Phone: 909-558-8142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA178872
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: