Healthcare Provider Details

I. General information

NPI: 1073506291
Provider Name (Legal Business Name): BENJAMIN R PROTO DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 OMNI BLVD SUITE 113
NEWPORT NEWS VA
23606
US

IV. Provider business mailing address

860 OMNI BLVD SUITE 303
NEWPORT NEWS VA
23606
US

V. Phone/Fax

Practice location:
  • Phone: 757-327-0657
  • Fax: 757-327-0658
Mailing address:
  • Phone: 757-232-8777
  • Fax: 757-232-8866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0103300835
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0103300835
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: