Healthcare Provider Details

I. General information

NPI: 1518036979
Provider Name (Legal Business Name): RICHARD EARL MINTER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 01/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 E GRANT ST STE 202
MACOMB IL
61455-3373
US

IV. Provider business mailing address

505 E GRANT ST STE 202
MACOMB IL
61455-3373
US

V. Phone/Fax

Practice location:
  • Phone: 309-833-1729
  • Fax:
Mailing address:
  • Phone: 309-833-1729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR4F20
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberR4F20
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.139552
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: