Provider Demographics
NPI:1063455756
Name:POTORSKI, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:POTORSKI
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 1:1159 NIKKI VIEW DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4879
Mailing Address - Country:US
Mailing Address - Phone:813-661-6199
Mailing Address - Fax:813-661-6199
Practice Address - Street 1:1159 NIKKI VIEW DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4879
Practice Address - Country:US
Practice Address - Phone:813-661-6199
Practice Address - Fax:813-661-6199
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114137207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME114137OtherMEDICAL LICENSE
PA001193645Medicaid
PA480106OtherHIGHMARK BLUE SHIELD
PA480106Medicare ID - Type Unspecified