Healthcare Provider Details

I. General information

NPI: 1528604253
Provider Name (Legal Business Name): MARK MINOR MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2019
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3021 W EAU GALLIE BLVD STE 102
MELBOURNE FL
32934-7005
US

IV. Provider business mailing address

3021 W EAU GALLIE BLVD STE 102
MELBOURNE FL
32934-7005
US

V. Phone/Fax

Practice location:
  • Phone: 321-757-5550
  • Fax: 321-255-5552
Mailing address:
  • Phone: 321-757-5550
  • Fax: 321-255-5552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK W MINOR
Title or Position: PRESIDENT
Credential: MD
Phone: 321-757-5550