Provider Demographics
NPI:1861588592
Name:POTOMAC UROLOGY CENTER, P.C.
Entity type:Organization
Organization Name:POTOMAC UROLOGY CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRATIK
Authorized Official - Middle Name:S
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-680-2111
Mailing Address - Street 1:2296 OPITZ BLVD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3300
Mailing Address - Country:US
Mailing Address - Phone:703-680-2111
Mailing Address - Fax:703-878-3939
Practice Address - Street 1:2296 OPITZ BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3300
Practice Address - Country:US
Practice Address - Phone:703-680-2111
Practice Address - Fax:703-878-3939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101027073208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4081469OtherAETNA
VA0675283010OtherCIGNA
VA23890001OtherCAREFIRST
VA002430OtherANTHEM
VADF9153OtherRR MEDICARE
VA1861588592Medicaid
VADF9153OtherRR MEDICARE