Provider Demographics
NPI:1720476245
Name:PROFETA, MATTHEW (PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:PROFETA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 8000 DEPT 314
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14267-0002
Mailing Address - Country:US
Mailing Address - Phone:716-213-0772
Mailing Address - Fax:716-324-5004
Practice Address - Street 1:2760 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-2702
Practice Address - Country:US
Practice Address - Phone:716-423-2262
Practice Address - Fax:716-423-2263
Is Sole Proprietor?:No
Enumeration Date:2015-01-06
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1253180225100000X
MD25221225100000X
VA2305209005225100000X
NY033901225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04425389Medicaid