Provider Demographics
NPI:1104110857
Name:SALEM, MUNKETH (DPM)
Entity type:Individual
Prefix:DR
First Name:MUNKETH
Middle Name:
Last Name:SALEM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5311 PATTERSON AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-2041
Mailing Address - Country:US
Mailing Address - Phone:804-285-1523
Mailing Address - Fax:
Practice Address - Street 1:5311 PATTERSON AVE
Practice Address - Street 2:STE 110
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2041
Practice Address - Country:US
Practice Address - Phone:804-285-1523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-29
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHXX213E00000X
VA0103301155213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVJ092AMedicare PIN