Healthcare Provider Details

I. General information

NPI: 1760477046
Provider Name (Legal Business Name): JEFFREY G MINER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 SHORE ROAD
WINCHESTER MA
01890
US

IV. Provider business mailing address

11 SHORE ROAD
WINCHESTER MA
01890
US

V. Phone/Fax

Practice location:
  • Phone: 781-729-1810
  • Fax: 978-683-0663
Mailing address:
  • Phone: 781-729-1810
  • Fax: 978-683-0663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number209739
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: