Provider Demographics
NPI:1073759635
Name:MALAVE, BENITO NMN (ORTHOTIST)
Entity Type:Individual
Prefix:MR
First Name:BENITO
Middle Name:NMN
Last Name:MALAVE
Suffix:
Gender:M
Credentials:ORTHOTIST
Other - Prefix:MR
Other - First Name:BENITO
Other - Middle Name:NMN
Other - Last Name:MALAVE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CO
Mailing Address - Street 1:100 EMANCIPATION DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23667-0001
Mailing Address - Country:US
Mailing Address - Phone:757-722-9961
Mailing Address - Fax:757-726-6076
Practice Address - Street 1:100 EMANCIPATION DR
Practice Address - Street 2:590/121
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23667-0001
Practice Address - Country:US
Practice Address - Phone:757-722-9961
Practice Address - Fax:757-726-6076
Is Sole Proprietor?:No
Enumeration Date:2008-12-31
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VACO003796174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist