Provider Demographics
NPI:1003920877
Name:POTTER, KIRK DAVID (DO)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:DAVID
Last Name:POTTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3012 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-1916
Mailing Address - Country:US
Mailing Address - Phone:785-301-2250
Mailing Address - Fax:785-301-2270
Practice Address - Street 1:3012 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-1916
Practice Address - Country:US
Practice Address - Phone:785-301-2250
Practice Address - Fax:785-301-2270
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-335282086S0122X, 208600000X, 208D00000X, 207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA34935OtherHEALTH PARTNERS
PA1613811OtherHIGHMARK BLUE SHIELD
PA2290955000OtherKEYSTONE IBC
KS200582300IMedicaid
PA1613811OtherPERSONAL CHOICE
PAP00189173OtherRAILROAD MEDICARE
PAI06540Medicare UPIN
PA1613811OtherPERSONAL CHOICE