Basic Information
| Provider Information | |||||||||
| NPI: | 1629027289 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MINKES | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11480 BROOKSHIRE AVE | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | DOWNEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902415010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629041651 | ||||||||
| FaxNumber: | 5629041656 | ||||||||
| Practice Location | |||||||||
| Address1: | 11480 BROOKSHIRE AVE | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | DOWNEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902415010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629041651 | ||||||||
| FaxNumber: | 5629041656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 07/24/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | G38259 | CA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | GR0080690 | 05 | CA | MEDICAID | GR0080690 | 01 | CA | MEDI-CAL | OTHER | 990004307 | 01 | CA | PALMETTO RAILROAD MEDICARE | OTHER | 0004024011 | 01 | CA | AETNA | OTHER | ZZZ54573Z | 01 | CA | BLUE SHIELD | OTHER |