Provider Demographics
NPI:1306807052
Name:MINERVA, KRISTEN (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:
Last Name:MINERVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 LEE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-1859
Mailing Address - Country:US
Mailing Address - Phone:407-647-2346
Mailing Address - Fax:407-647-5431
Practice Address - Street 1:1950 LEE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-1859
Practice Address - Country:US
Practice Address - Phone:407-647-2346
Practice Address - Fax:407-647-5431
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88782207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL48125OtherBCBS
FL277609OtherAVMED
FLP00226763OtherRAIL ROAD MEDICARE
FL48126ZMedicare ID - Type Unspecified
FLP00226763OtherRAIL ROAD MEDICARE