Provider Demographics
NPI:1255996906
Name:MINALDI, ELLEN LANDRY (MD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:LANDRY
Last Name:MINALDI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:MARGARET
Other - Last Name:LANDRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5 PROFESSIONAL PLZ
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-1900
Mailing Address - Country:US
Mailing Address - Phone:623-381-1916
Mailing Address - Fax:662-338-1191
Practice Address - Street 1:5 PROFESSIONAL PLZ
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-1900
Practice Address - Country:US
Practice Address - Phone:623-230-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2022-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MS30032208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program