Provider Demographics
NPI:1194759175
Name:PROFETA, SUSAN B (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
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 1:1 HICKORY DR
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-2107
Mailing Address - Country:US
Mailing Address - Phone:973-762-0905
Mailing Address - Fax:
Practice Address - Street 1:33 OVERLOOK RD
Practice Address - Street 2:SUITE 306
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-3570
Practice Address - Country:US
Practice Address - Phone:908-598-0606
Practice Address - Fax:908-598-1955
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04377900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C56567Medicare UPIN