Provider Demographics
NPI:1609861202
Name:MINNICK, KATHLEEN ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ELIZABETH
Last Name:MINNICK
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:PO BOX 20800
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4105
Mailing Address - Country:US
Mailing Address - Phone:561-270-5505
Mailing Address - Fax:561-437-0177
Practice Address - Street 1:11551 SOUTHERN BLVD STE 2
Practice Address - Street 2:
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-4254
Practice Address - Country:US
Practice Address - Phone:561-270-5505
Practice Address - Fax:561-437-0177
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 78137208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4586865OtherAETNA
FLP971167OtherOPTIMUM
FL1023956OtherCAREPLUS
FL1092080OtherWELLCARE
FL259940OtherAVMED
FL256694000Medicaid
FL46572OtherBCBS
FL8877OtherDIMENSION
FLP1035432OtherFREEDOM
FL4586865OtherAETNA
FL259940OtherAVMED
FL46572ZMedicare PIN