Provider Demographics
NPI:1982609657
Name:MINOR, MARK W (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:MINOR
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3021 W EAU GALLIE BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-7005
Mailing Address - Country:US
Mailing Address - Phone:321-757-5550
Mailing Address - Fax:321-255-5552
Practice Address - Street 1:3021 W EAU GALLIE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7005
Practice Address - Country:US
Practice Address - Phone:321-757-5550
Practice Address - Fax:321-255-5552
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0045859207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1762243003OtherCIGNA
FL4038851OtherAETNA
FL26075OtherBCBS
FL1762243003OtherCIGNA
FL26075VMedicare PIN
FL4038851OtherAETNA