Healthcare Provider Details

I. General information

NPI: 1366441354
Provider Name (Legal Business Name): JOSEPH J MINISSALE JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 GLEN COVE DR
ROCKPORT ME
04856-4235
US

IV. Provider business mailing address

701 OSTRUM ST STE 201
FOUNTAIN HILL PA
18015-1152
US

V. Phone/Fax

Practice location:
  • Phone: 207-301-5790
  • Fax:
Mailing address:
  • Phone: 484-526-6545
  • Fax: 484-526-6546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberDO2986
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberOS007619L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: