Provider Demographics
NPI:1477579837
Name:PROFETA, BERNADETTE CAROL (MD)
Entity Type:Individual
Prefix:DR
First Name:BERNADETTE
Middle Name:CAROL
Last Name:PROFETA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 S CHICKASAW TRL STE 301
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-3501
Mailing Address - Country:US
Mailing Address - Phone:407-303-7399
Mailing Address - Fax:407-303-7305
Practice Address - Street 1:258 S CHICKASAW TRL STE 301
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-3501
Practice Address - Country:US
Practice Address - Phone:407-303-7399
Practice Address - Fax:407-303-7305
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD069235L208600000X
NJ25MA08750100208600000X
FLME120470208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0075868Medicaid
PA101076919Medicaid
PA101076919Medicaid