Healthcare Provider Details

I. General information

NPI: 1114486115
Provider Name (Legal Business Name): MATTHEW CARROLL MINNETTE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

PO BOX 100296
GAINESVILLE FL
32610-0296
US

V. Phone/Fax

Practice location:
  • Phone: 352-627-9350
  • Fax: 352-273-9054
Mailing address:
  • Phone: 352-627-9350
  • Fax: 352-273-9054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036160247
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2022004027
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME168009
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: