Healthcare Provider Details

I. General information

NPI: 1376828178
Provider Name (Legal Business Name): MAXINE MINTO MD P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 10/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 INTERNATIONAL PKWY SUITE 2000
LAKE MARY FL
32746-4713
US

IV. Provider business mailing address

10524 MOSS PARK RD SUITE 204-516
ORLANDO FL
32832-5898
US

V. Phone/Fax

Practice location:
  • Phone: 407-536-5375
  • Fax: 407-536-5301
Mailing address:
  • Phone: 407-536-5375
  • Fax: 407-536-5301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberME69898
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberME69898
License Number StateFL

VIII. Authorized Official

Name: DR. MAXINE JOAN MINTO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 407-536-5375