Provider Demographics
NPI:1578637633
Name:MANASSAS FOOT CLINIC INC
Entity Type:Organization
Organization Name:MANASSAS FOOT CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:M
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:703-361-3132
Mailing Address - Street 1:8704 ROLLING RD
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4253
Mailing Address - Country:US
Mailing Address - Phone:703-361-3132
Mailing Address - Fax:703-368-0291
Practice Address - Street 1:8704 ROLLING RD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4253
Practice Address - Country:US
Practice Address - Phone:703-361-3132
Practice Address - Fax:703-368-0291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103001009213ES0103X
VA0103000268213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7134OtherCAREFIRST
VA035461OtherBLUE SHIELD
VA009300627Medicaid
21906OtherUNITEDHEALTHCARE
VA4813150001Medicare NSC
21906OtherUNITEDHEALTHCARE