Provider Demographics
NPI:1083657183
Name:POTOMSKI, JOHN H JR (DO CMA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:H
Last Name:POTOMSKI
Suffix:JR
Gender:M
Credentials:DO CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 E NEW HAVEN AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-5474
Mailing Address - Country:US
Mailing Address - Phone:321-724-4545
Mailing Address - Fax:321-728-4168
Practice Address - Street 1:720 E NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901
Practice Address - Country:US
Practice Address - Phone:321-724-4545
Practice Address - Fax:321-728-4168
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4425207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067596200Medicaid
FL067596200Medicaid
FL82524ZMedicare ID - Type Unspecified
FL067596200Medicaid