Healthcare Provider Details

I. General information

NPI: 1376979567
Provider Name (Legal Business Name): BORISLAV CICMIL DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2013
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7811 MONTROSE RD STE 340
POTOMAC MD
20854-3363
US

IV. Provider business mailing address

7811 MONTROSE RD STE 340
POTOMAC MD
20854-3363
US

V. Phone/Fax

Practice location:
  • Phone: 301-588-7888
  • Fax: 301-588-3419
Mailing address:
  • Phone: 301-588-7888
  • Fax: 301-588-3419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number24706
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: