Provider Demographics
NPI:1285212233
Name:POTOMAC UROLOGY CENTER, P.C.
Entity Type:Organization
Organization Name:POTOMAC UROLOGY CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PRATIK
Authorized Official - Middle Name:S
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-680-2111
Mailing Address - Street 1:2296 OPITZ BLVD STE 304
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3354
Mailing Address - Country:US
Mailing Address - Phone:703-680-2111
Mailing Address - Fax:703-878-3939
Practice Address - Street 1:251 NATIONAL HARBOR BLVD STE 400
Practice Address - Street 2:
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-1052
Practice Address - Country:US
Practice Address - Phone:301-637-7878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1861588592Medicaid