Provider Demographics
NPI:1033170063
Name:MINZNER, JON RAYMOND (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:RAYMOND
Last Name:MINZNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-578-3400
Mailing Address - Fax:859-957-0055
Practice Address - Street 1:2765 CHAPEL PL
Practice Address - Street 2:SUITE 200
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3413
Practice Address - Country:US
Practice Address - Phone:859-578-3400
Practice Address - Fax:859-957-0055
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35639207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64012800Medicaid
OH2387975Medicaid
KYP00327046OtherRAILROAD MEDICARE
KY64012800Medicaid
OH2387975Medicaid
KY008580083Medicare PIN