Provider Demographics
NPI:1659741742
Name:LANSDOWNE PODIATRY
Entity Type:Organization
Organization Name:LANSDOWNE PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:ROLLE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:571-223-0424
Mailing Address - Street 1:10845 PHILADELPHIA RD
Mailing Address - Street 2:
Mailing Address - City:WHITE MARSH
Mailing Address - State:MD
Mailing Address - Zip Code:21162-1717
Mailing Address - Country:US
Mailing Address - Phone:410-335-0008
Mailing Address - Fax:410-335-3113
Practice Address - Street 1:44135 WOODRIDGE PKWY
Practice Address - Street 2:SUITE 180
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-1244
Practice Address - Country:US
Practice Address - Phone:571-223-0424
Practice Address - Fax:571-223-0425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-01
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAF094OtherMEDICARE
VA1659741742OtherMEDICAL ASSISTANCE
DC228056Medicare PIN