Provider Demographics
NPI:1003088626
Name:POTTER OPTOMETRY, INC.
Entity Type:Organization
Organization Name:POTTER OPTOMETRY, INC.
Other - Org Name:PERSONAL EYECARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROXANNA
Authorized Official - Middle Name:T
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:419-705-5143
Mailing Address - Street 1:8006 N BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-9495
Mailing Address - Country:US
Mailing Address - Phone:419-885-5300
Mailing Address - Fax:
Practice Address - Street 1:8254 MAYBERRY SQ N
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-9457
Practice Address - Country:US
Practice Address - Phone:419-885-5300
Practice Address - Fax:419-885-5308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5738/T2652152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2831467Medicaid
OHPO9376401Medicare PIN
OH2831467Medicaid