Provider Demographics
NPI:1215021506
Name:POTOMAC CARDIOVASCULAR CONSULTANTS, LLC
Entity type:Organization
Organization Name:POTOMAC CARDIOVASCULAR CONSULTANTS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIANO
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHUTUAPE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-730-8002
Mailing Address - Street 1:2280 OPITZ BLVD STE 260
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3362
Mailing Address - Country:US
Mailing Address - Phone:703-730-8002
Mailing Address - Fax:703-730-8025
Practice Address - Street 1:2010 OPITZ BLVD STE C
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3359
Practice Address - Country:US
Practice Address - Phone:703-730-8002
Practice Address - Fax:703-730-8025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RC0000X
VA101053905261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC1619OtherMEDICARE RAILROAD
DC1619OtherMEDICARE RAILROAD
VAG04324Medicare UPIN
VAC08995Medicare PIN