Provider Demographics
NPI:1376795765
Name:ASSOCIATED FOOT & ANKLE CENTERS OF NORTHERN VIRGINIA PC
Entity Type:Organization
Organization Name:ASSOCIATED FOOT & ANKLE CENTERS OF NORTHERN VIRGINIA PC
Other - Org Name:LAKERIDGE FOOT & ANKLE CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:STABILE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:703-491-9500
Mailing Address - Street 1:1721 FINANCIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:LAKE RIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2460
Mailing Address - Country:US
Mailing Address - Phone:703-491-9500
Mailing Address - Fax:703-491-9994
Practice Address - Street 1:10730 MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-3704
Practice Address - Country:US
Practice Address - Phone:703-691-0670
Practice Address - Fax:703-385-2865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-16
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000774213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG01779D01Medicare PIN