Provider Demographics
NPI:1386281582
Name:MALDONADO, MINERVA (LO)
Entity type:Individual
Prefix:
First Name:MINERVA
Middle Name:
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 WOLCOTT ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-1317
Mailing Address - Country:US
Mailing Address - Phone:203-759-1611
Mailing Address - Fax:203-759-1707
Practice Address - Street 1:910 WOLCOTT ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-1317
Practice Address - Country:US
Practice Address - Phone:203-759-1611
Practice Address - Fax:203-759-1707
Is Sole Proprietor?:No
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1814156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician