Healthcare Provider Details

I. General information

NPI: 1851804777
Provider Name (Legal Business Name): MINA ESTAFANOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 04/15/2024
Certification Date: 04/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8522 PINE RUN CT
ELLICOTT CITY MD
21043-6934
US

IV. Provider business mailing address

8522 PINE RUN CT
ELLICOTT CITY MD
21043-6934
US

V. Phone/Fax

Practice location:
  • Phone: 917-929-7989
  • Fax:
Mailing address:
  • Phone: 917-929-7989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number24985
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberNA
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: