Provider Demographics
NPI:1467533471
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 CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:JEFFERY
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:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2460
Mailing Address - Country:US
Mailing Address - Phone:703-491-9500
Mailing Address - Fax:
Practice Address - Street 1:1721 FINANCIAL LOOP
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2460
Practice Address - Country:US
Practice Address - Phone:703-491-9500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0799830001Medicare NSC