MEDICARE: POTOMAC PODIATRY ASSOCIATES LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	0103000339	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780866178
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POTOMAC PODIATRY ASSOCIATES LTD

Provider Business Mailing Address
First Line	:	15700 CHAPMAN PL
Second Line	:
City	:	MONTCLAIR
State	:	VA
Zip	:	22025-1315
Country	:	US
Telephone Number	:	703-370-5533
Fax Number	:	703-680-9579

Provider Business Practice Location Address
First Line	:	15700 CHAPMAN PL
Second Line	:
City	:	MONTCLAIR
State	:	VA
Zip	:	22025-1315
Country	:	US
Telephone Number	:	703-370-5533
Fax Number	:	703-680-9579

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	DR. JEROME LOUIS DOVBERG
Credential	:	DPM
Telephone Number	:	703-370-5533

Provider Enumeration Date	:	11/28/2007
Last Update Date	:	05/17/2013

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