Provider Demographics
NPI:1043207657
Name:POTTER, CHRISTOPHER (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:
Last Name:POTTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 41113
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-1113
Mailing Address - Country:US
Mailing Address - Phone:904-376-4400
Mailing Address - Fax:904-249-9764
Practice Address - Street 1:1370 13TH AVE S STE 215
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3206
Practice Address - Country:US
Practice Address - Phone:904-249-1041
Practice Address - Fax:904-249-9764
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME789872084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001841300Medicaid
FL47298WMedicare PIN
FL001841300Medicaid