Provider Demographics
NPI:1972171411
Name:POTOMAC PODIATRY PLLC
Entity Type:Organization
Organization Name:POTOMAC PODIATRY PLLC
Other - Org Name:CROFTON PODIATRY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BONINI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:301-200-3040
Mailing Address - Street 1:14010 SMOKETOWN RD STE 103
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-4723
Mailing Address - Country:US
Mailing Address - Phone:703-583-5959
Mailing Address - Fax:703-583-5995
Practice Address - Street 1:1657 CROFTON BLVD STE 201
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-1352
Practice Address - Country:US
Practice Address - Phone:410-721-4505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POTOMAC PODIATRY PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-11
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty