Provider Demographics
NPI:1528178977
Name:MINAS, MICHAEL R, (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R,
Last Name:MINAS
Suffix:
Gender:M
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:PO BOX 1909
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-9108
Mailing Address - Country:US
Mailing Address - Phone:208-939-3314
Mailing Address - Fax:208-939-3315
Practice Address - Street 1:100 COTTONWOOD CT
Practice Address - Street 2:SUITE 150
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6545
Practice Address - Country:US
Practice Address - Phone:208-939-3314
Practice Address - Fax:208-939-3315
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-8587207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID841636078OtherTAX I. D. NUMBER
ID806518400Medicaid
ID841636078OtherTAX I. D. NUMBER