Provider Demographics
NPI:1225466485
Name:CAPITAL FOOT & ANKLE CARE CENTRE, PA
Entity Type:Organization
Organization Name:CAPITAL FOOT & ANKLE CARE CENTRE, PA
Other - Org Name:LEONARDTOWN FOOT & ANKLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:VANFOSSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:301-862-3338
Mailing Address - Street 1:PO BOX 1310
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA
Mailing Address - State:MD
Mailing Address - Zip Code:20619-1310
Mailing Address - Country:US
Mailing Address - Phone:301-862-3338
Mailing Address - Fax:301-862-3335
Practice Address - Street 1:22680 CEDAR LANE CT OFC 2
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-3910
Practice Address - Country:US
Practice Address - Phone:301-862-3338
Practice Address - Fax:301-862-3335
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAPITAL FOOT & ANKLE CARE CENTRE, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-28
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00975213E00000X
MD01346213ES0103X
MD01511213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD77230001OtherBLUE CROSS BLUE SHIELD
MD231308100Medicaid
MD539LMedicare PIN
MD77230001OtherBLUE CROSS BLUE SHIELD