Provider Demographics
NPI:1922009703
Name:DOMINION FOOT & ANKLE CONSULTANTS PC
Entity Type:Organization
Organization Name:DOMINION FOOT & ANKLE CONSULTANTS PC
Other - Org Name:WOODBURN PODIATRY CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:PONTELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:703-849-8400
Mailing Address - Street 1:3025 HAMAKER CT
Mailing Address - Street 2:#340
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2237
Mailing Address - Country:US
Mailing Address - Phone:703-849-8400
Mailing Address - Fax:703-849-8448
Practice Address - Street 1:3025 HAMAKER CT
Practice Address - Street 2:#340
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2237
Practice Address - Country:US
Practice Address - Phone:703-849-8400
Practice Address - Fax:703-849-8448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG00455Medicare PIN
VA0614830001Medicare NSC