Healthcare Provider Details

I. General information

NPI: 1902182660
Provider Name (Legal Business Name): CLIFTON FOOT AND ANKLE CENTER P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2011
Last Update Date: 05/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6101 REDWOOD SQUARE CENTER SUITE 303
CENTREVILLE VA
20121-4269
US

IV. Provider business mailing address

6101 REDWOOD SQUARE CTR SUITE 303
CENTREVILLE VA
20121-4265
US

V. Phone/Fax

Practice location:
  • Phone: 703-996-3000
  • Fax: 703-229-1152
Mailing address:
  • Phone: 703-996-3000
  • Fax: 703-229-1152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0103000986
License Number StateVA

VIII. Authorized Official

Name: DR. KENNETH REED WILHELM
Title or Position: PRESIDENT
Credential: DPM
Phone: 703-996-3000