Provider Demographics
NPI:1114993367
Name:POTOLICCHIO, SAMUEL J JR (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:J
Last Name:POTOLICCHIO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:5214 ALBEMARLE ST
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20816-1829
Mailing Address - Country:US
Mailing Address - Phone:301-602-2906
Mailing Address - Fax:301-246-8628
Practice Address - Street 1:4940 HAMPDEN LN STE 300
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-2968
Practice Address - Country:US
Practice Address - Phone:301-652-7155
Practice Address - Fax:301-246-8628
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101052485207T00000X, 2084N0400X, 2084N0400X
MDD0042536207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
O36590Medicare UPIN
DC000W03M83Medicare ID - Type Unspecified
C88624Medicare UPIN
C88624Medicare UPIN
DC000W03M83Medicare ID - Type Unspecified
VA007103239Medicaid