Provider Demographics
NPI:1477731974
Name:PROPHETE, JUDITH (MD)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:
Last Name:PROPHETE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:COMEAU
Other - Last Name:SAMUEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5000 PARKSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-4714
Mailing Address - Country:US
Mailing Address - Phone:732-979-5810
Mailing Address - Fax:
Practice Address - Street 1:5000 PARKSIDE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-4714
Practice Address - Country:US
Practice Address - Phone:732-979-5810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 043080E207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA725985Medicaid