Provider Demographics
NPI:1902973423
Name:CENTER FOR PRIMARY CARE & GERIATRICS
Entity Type:Organization
Organization Name:CENTER FOR PRIMARY CARE & GERIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CISSY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:POTTANAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD MPH
Authorized Official - Phone:703-532-9411
Mailing Address - Street 1:6319 CASTLE PLACE
Mailing Address - Street 2:SUITE #3D
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22044-1907
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2023-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101056325207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5628997Medicaid
287222OtherANTHEM
49D0222254OtherCLIA #
F383001OtherCAREFIRST
VA5628997Medicaid