Healthcare Provider Details

I. General information

NPI: 1740705888
Provider Name (Legal Business Name): GURVIKRAM BOPARAI DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2017
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14605 POTOMAC BRANCH DR STE 300
WOODBRIDGE VA
22191-3337
US

IV. Provider business mailing address

14605 POTOMAC BRANCH DR
WOODBRIDGE VA
22191-3336
US

V. Phone/Fax

Practice location:
  • Phone: 703-490-1112
  • Fax:
Mailing address:
  • Phone: 703-490-1112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0103301329
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0103301329
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: