Dominion Primary Care – Interventional Pain Medicine Physician, NPI 1104467463
Interventional Pain Medicine Physician
Main info
Profile Insights
NPPES metrics only — not quality of care.
Provider Addresses for Dominion Primary Care
2296 Opitz Blvd Ste 110120
Woodbridge, VA 221913300
Phone: (301) 829-7693
Fax: (301) 829-7694
Type: Location
6128 Brandon Ave Ste 208210
Springfield, VA 221502640
Phone: (301) 659-0003
Fax: (301) 829-7694
Type: Location
2952 BONDS RIDGE CT
OAKTON, VA 221241778
Phone: (419) 819-7394
Type: Mailing
12070 OLD LINE CTR
WALDORF, MD 206022513
Phone: (571) 633-5017
Type: Location
2296 Opitz Blvd Ste 208210
Woodbridge, VA 221913300
Phone: (301) 829-7693
Type: Location
3500 Old Washington Rd Ste 202
Waldorf, MD 206023238
Phone: (301) 659-0003
Type: Location
6128 BRANDON AVE STE 208210
SPRINGFIELD, VA 221502640
Phone: (301) 659-0003
Fax: (301) 829-7694
Type: Location
2296 OPITZ BLVD
STE 110 - 120
WOODBRIDGE, VA 221913300
Phone: (301) 829-7693
Fax: (301) 829-7694
Type: Mailing
3500 OLD WASHINGTON RD STE 202
WALDORF, MD 206023238
Phone: (301) 659-0003
Type: Location
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
No Open Payments data available for this provider.
This can happen when there are no reportable CMS Open Payments records.
Medicare Enrollment & Revalidation
Source: CMS public data · Not endorsed by CMS ·
Educational use only—not medical, billing, or legal advice.
PECOS enrollment status
Participating (accepts Medicare assignment)
Enrollment effective: 2024-10-03
PECOS data refreshed: 2026-05-27
Medicare revalidation (CMS due date list)
Past revalidation due date
Earliest CMS due date was 2025-09-30 (252 days ago).
Enrollment records
3
Earliest due date
2025-09-30
CMS data updated
2026-06-01
Revalidation progress
- Medicare enrolled
- On CMS revalidation list
- Due date assigned
- Revalidate in PECOS
CMS enrollment records
| Enrollment ID | Type | Specialty | State | Due date |
|---|---|---|---|---|
| O20200109001885 | O | Clinic/Group Practice | MD | 2025-09-30 |
| O20200915000926 | O | Clinic/Group Practice | DC | 2026-02-28 |
| O20241003000207 | O | Clinic/Group Practice | VA | TBD |
What to do next
- Verify current status on the CMS Revalidation Lookup Tool immediately.
- Complete revalidation in PECOS or contact your Medicare Administrative Contractor (MAC).
- Overdue revalidation can lead to deactivation of Medicare billing privileges.
Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS
Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
Educational use only—not medical, billing, or legal advice.
No Medicare fee-for-service utilization data available for this provider in our database.
Insurance plans in this area (ZIP 22191)
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