Healthcare Provider Details

I. General information

NPI: 1609195452
Provider Name (Legal Business Name): JONATHAN LEE MINOR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2010
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 W 10TH ST
ROLLA MO
65409-6519
US

IV. Provider business mailing address

910 W 10TH ST
ROLLA MO
65409-6519
US

V. Phone/Fax

Practice location:
  • Phone: 573-342-4284
  • Fax: 573-341-6967
Mailing address:
  • Phone: 573-342-4284
  • Fax: 573-341-6967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberA137057
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2020036607
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierCB238713
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerMEDICARE PTAN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: