Provider Demographics
NPI:1356497622
Name:PROFERA, BENEDICT A (DPM, MPH)
Entity Type:Individual
Prefix:DR
First Name:BENEDICT
Middle Name:A
Last Name:PROFERA
Suffix:
Gender:M
Credentials:DPM, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1589 INNSBROOKE DR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-1785
Mailing Address - Country:US
Mailing Address - Phone:540-389-6267
Mailing Address - Fax:
Practice Address - Street 1:1589 INNSBROOKE DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-1785
Practice Address - Country:US
Practice Address - Phone:540-389-6267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000566213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010265851Medicaid
VA190001354Medicare ID - Type Unspecified