Provider Demographics
NPI:1366441354
Name:MINISSALE, JOSEPH J JR (DO)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:J
Last Name:MINISSALE
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 OSTRUM ST STE 201
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILL
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1152
Mailing Address - Country:US
Mailing Address - Phone:484-526-6545
Mailing Address - Fax:484-526-6546
Practice Address - Street 1:4 GLEN COVE DR
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-4235
Practice Address - Country:US
Practice Address - Phone:207-301-5790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO2986207RG0100X
PAOS007619L207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016078690002Medicaid
PAG26067Medicare UPIN
PA863145Medicare PIN