Healthcare Provider Details

I. General information

NPI: 1396743688
Provider Name (Legal Business Name): ERIC B MASTERNICK D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 12/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 TOWN CENTER DR SUITE 220
RESTON VA
20190-5896
US

IV. Provider business mailing address

1600 E GUDE DR SUITE 200
ROCKVILLE MD
20850-1341
US

V. Phone/Fax

Practice location:
  • Phone: 703-391-0211
  • Fax: 703-880-1192
Mailing address:
  • Phone: 301-933-7133
  • Fax: 301-933-7137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0103300997
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: