Healthcare Provider Details

I. General information

NPI: 1215021506
Provider Name (Legal Business Name): POTOMAC CARDIOVASCULAR CONSULTANTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 OPITZ BLVD STE C
WOODBRIDGE VA
22191-3359
US

IV. Provider business mailing address

2280 OPITZ BLVD STE 260
WOODBRIDGE VA
22191-3362
US

V. Phone/Fax

Practice location:
  • Phone: 703-730-8002
  • Fax: 703-730-8025
Mailing address:
  • Phone: 703-730-8002
  • Fax: 703-730-8025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number101053905
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARIANO D. CHUTUAPE
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 703-730-8002