Provider Demographics
NPI:1780866178
Name:POTOMAC PODIATRY ASSOCIATES LTD
Entity Type:Organization
Organization Name:POTOMAC PODIATRY ASSOCIATES LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:DOVBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:703-370-5533
Mailing Address - Street 1:15700 CHAPMAN PL
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:VA
Mailing Address - Zip Code:22025-1315
Mailing Address - Country:US
Mailing Address - Phone:703-370-5533
Mailing Address - Fax:703-680-9579
Practice Address - Street 1:15700 CHAPMAN PL
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:VA
Practice Address - Zip Code:22025-1315
Practice Address - Country:US
Practice Address - Phone:703-370-5533
Practice Address - Fax:703-680-9579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000339213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA09301127Medicaid
DCU24356Medicare UPIN
DC199095Medicare PIN
VA5653280001Medicare NSC