NPIMap

Organization Active NPI

Potomac Podiatry PLLC

  • Foot & Ankle Surgery Podiatrist
  • Crofton, MD
National Provider Identifier
1972171411
Registry record updated Nov 5, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Foot & Ankle Surgery PodiatristTaxonomy code 213ES0103X
Legal business name
POTOMAC PODIATRY PLLC
Practice address
1657 Crofton Blvd Ste 201
Crofton, MD 21114-1352
Phone
(410) 721-4505
NPI assigned
Jun 11, 2021
Organization subpart
Yes
Parent organization
POTOMAC PODIATRY PLLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 5, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Vincent Joseph Bonini, DPMNPI 1790892131
Title
Owner
Phone
(301) 200-3040

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Foot & Ankle Surgery PodiatristGroup: 193400000X SINGLE SPECIALTY GROUP 213ES0103X Primary

Addresses

Primary practice location

1657 Crofton Blvd Ste 201
Crofton, MD 21114-1352

Mailing address

14010 Smoketown Rd Ste 103
Woodbridge, VA 22192-4723
Phone (703) 583-5959

Other practice location 1

2411 Crofton Ln Ste 25
Crofton, MD 21114-1304
Phone (410) 721-4505

Other names 1

  • Crofton Podiatry Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MD

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220407002247 MD DME Supplier - Physician - Podiatry 8527086834 Practice locations: Crofton, MD

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Potomac Podiatry PLLC4 organizations share this tax ID, including this one
Part of
Potomac Podiatry PLLC

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1657 Crofton Blvd
Ste 201
Crofton, MD 21114
Phone (410) 721-4505

3914 Centreville Rd
Ste 200
Chantilly, VA 20151
Phone (571) 639-9220

14010 Smoketown Rd
Ste 103
Woodbridge, VA 22192
Phone (571) 402-7322

2280 Opitz Blvd
#2230
Woodbridge, VA 22191
Phone (703) 583-5959

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1623369600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1636070400000",
    "number": "1972171411",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "14010 SMOKETOWN RD STE 103",
            "city": "WOODBRIDGE",
            "state": "VA",
            "postal_code": "221924723",
            "telephone_number": "703-583-5959",
            "fax_number": "703-583-5995"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1657 CROFTON BLVD STE 201",
            "city": "CROFTON",
            "state": "MD",
            "postal_code": "211141352",
            "telephone_number": "410-721-4505"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2411 Crofton Ln Ste 25",
            "address_purpose": "LOCATION",
            "city": "Crofton",
            "state": "MD",
            "postal_code": "211141304",
            "country_code": "US",
            "telephone_number": "410-721-4505",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "POTOMAC PODIATRY PLLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "POTOMAC PODIATRY PLLC",
        "enumeration_date": "2021-06-11",
        "last_updated": "2021-11-05",
        "certification_date": "2021-11-05",
        "status": "A",
        "authorized_official_last_name": "BONINI",
        "authorized_official_first_name": "VINCENT",
        "authorized_official_middle_name": "JOSEPH",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "301-200-3040",
        "authorized_official_credential": "DPM"
    },
    "taxonomies": [
        {
            "code": "213ES0103X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Podiatrist, Foot & Ankle Surgery",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Crofton Podiatry",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Crofton Podiatry",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Crofton, MD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 5, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.