Basic Information
| Provider Information | |||||||||
| NPI: | 1770014193 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARK | ||||||||
| FirstName: | SAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARK | ||||||||
| OtherFirstName: | OI WING | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | DPM | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 224D CORNWALL ST NW STE 403 | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201762704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037376001 | ||||||||
| FaxNumber: | 7034438643 | ||||||||
| Practice Location | |||||||||
| Address1: | 4660 KENMORE AVE STE 608 | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223041306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035784161 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2017 | ||||||||
| LastUpdateDate: | 09/16/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 0103301337 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.