Provider Demographics
NPI:1366571085
Name:MINKOFF, LARRY HOWARD (DPM)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:HOWARD
Last Name:MINKOFF
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LUZERNE
Mailing Address - State:PA
Mailing Address - Zip Code:18709-1256
Mailing Address - Country:US
Mailing Address - Phone:570-288-2866
Mailing Address - Fax:570-288-2866
Practice Address - Street 1:70 MAIN ST
Practice Address - Street 2:
Practice Address - City:LUZERNE
Practice Address - State:PA
Practice Address - Zip Code:18709-1256
Practice Address - Country:US
Practice Address - Phone:570-288-2866
Practice Address - Fax:570-288-2866
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002884L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011633790002Medicaid
PA0011633790002Medicaid
T30562Medicare UPIN