Healthcare Provider Details

I. General information

NPI: 1871567594
Provider Name (Legal Business Name): BETTY M MINA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12220 ATLANTIC BLVD #112
JACKSONVILLE FL
32225-5822
US

IV. Provider business mailing address

13241 BARTRAM PARK BLVD #209
JACKSONVILLE FL
32258-5212
US

V. Phone/Fax

Practice location:
  • Phone: 904-220-8883
  • Fax: 904-220-8884
Mailing address:
  • Phone: 904-242-4220
  • Fax: 904-220-8884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0045858
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: