Provider Demographics
NPI:1144360058
Name:PODIATRIC CARE OF NORTHERN VIRGINIA, PC
Entity type:Organization
Organization Name:PODIATRIC CARE OF NORTHERN VIRGINIA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:IRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-727-3689
Mailing Address - Street 1:PO BOX 234
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:VA
Mailing Address - Zip Code:20197-0234
Mailing Address - Country:US
Mailing Address - Phone:703-727-3689
Mailing Address - Fax:
Practice Address - Street 1:821 S KING ST STE I
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175-3922
Practice Address - Country:US
Practice Address - Phone:703-727-3689
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0244550001Medicare NSC
VAC09746Medicare PIN