Healthcare Provider Details

I. General information

NPI: 1982609657
Provider Name (Legal Business Name): MARK W MINOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
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 NumberME0045859
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: