Healthcare Provider Details

I. General information

NPI: 1528178977
Provider Name (Legal Business Name): MICHAEL R, MINAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 01/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 COTTONWOOD CT SUITE 150
EAGLE ID
83616-6545
US

IV. Provider business mailing address

PO BOX 1909
EAGLE ID
83616-9108
US

V. Phone/Fax

Practice location:
  • Phone: 208-939-3314
  • Fax: 208-939-3315
Mailing address:
  • Phone: 208-939-3314
  • Fax: 208-939-3315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-8587
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: