Healthcare Provider Details

I. General information

NPI: 1639380694
Provider Name (Legal Business Name): MINTA PAMELA SPAIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 PELHAM PARKWAY SOUTH NR 3N7
BRONX NY
10461
US

IV. Provider business mailing address

PO BOX 1465
NEW YORK NY
10159-1465
US

V. Phone/Fax

Practice location:
  • Phone: 718-918-3886
  • Fax: 718-918-7526
Mailing address:
  • Phone: 718-918-3886
  • Fax: 718-918-7526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number192304
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: