Provider Demographics
NPI:1073958526
Name:POTTER, CHRISTOPHER DAVID (DPT)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:DAVID
Last Name:POTTER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 MALIBU DR
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-9713
Mailing Address - Country:US
Mailing Address - Phone:262-329-2700
Mailing Address - Fax:
Practice Address - Street 1:975 PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-9201
Practice Address - Country:US
Practice Address - Phone:262-329-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11112-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist