Provider Demographics
NPI:1295802718
Name:POTTANAT, CISSY PAUL (MD MPH)
Entity type:Individual
Prefix:DR
First Name:CISSY
Middle Name:PAUL
Last Name:POTTANAT
Suffix:
Gender:F
Credentials:MD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7115 LEESBURG PIKE STE 211
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22043-2301
Mailing Address - Country:US
Mailing Address - Phone:703-532-1111
Mailing Address - Fax:703-532-3224
Practice Address - Street 1:7115 LEESBURG PIKE STE 211
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22043-2301
Practice Address - Country:US
Practice Address - Phone:703-532-1111
Practice Address - Fax:703-532-3224
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052635207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
49D02222254OtherCLIA#
F383001OtherCALLFIRST
287222OtherANTHEM
VA5628997Medicaid
49D02222254OtherCLIA#
00A818C81Medicare ID - Type Unspecified