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General NPI Number Information
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NPI Number | 1114993367
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Entity Type | Individual
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Provider Name | SAMUEL J POTOLICCHIO JR. MD
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Gender | Male
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Dates
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Enumeration Date | 02/27/2006
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Last Update Date | 02/14/2024
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Provider Practice Location Address
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Address Line | 4940 HAMPDEN LN STE 300
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City | BETHESDA
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State | MD
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Zip | 20814-2968
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Country | US
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Telephone | 301-652-7155
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Fax | 301-246-8628
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Provider Business Mailing Address
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Address Line | 5214 ALBEMARLE ST
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City | BETHESDA
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State | MD
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Zip | 20816-1829
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Country | US
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Telephone | 301-602-2906
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Fax | 301-246-8628
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207T00000X
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Taxonomy Name | Neurological Surgery Physician
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License Number | 0101052485
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 0101052485
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 207T00000X
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Taxonomy Name | Neurological Surgery Physician
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License Number | D0042536
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License Number State | MD
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