Basic Information
| Provider Information | |||||||||
| NPI: | 1790745032 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHN | ||||||||
| FirstName: | MINNIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5444 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100875444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187805260 | ||||||||
| FaxNumber: | 7187803266 | ||||||||
| Practice Location | |||||||||
| Address1: | 263 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112157247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187805260 | ||||||||
| FaxNumber: | 7187803266 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 12/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/18/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 223528 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0208X | 223528 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases |
ID Information
| ID | Type | State | Issuer | Description | 02586969 | 05 | NY | MEDICAID |