Provider Demographics
NPI:1093785180
Name:POTTER, JON WARREN (DO)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:WARREN
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 1:3940 OAKWOOD HILLS PKWY STE 2
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-8888
Mailing Address - Country:US
Mailing Address - Phone:715-552-7303
Mailing Address - Fax:715-552-7355
Practice Address - Street 1:3940 OAKWOOD HILLS PKWY STE 2
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-8888
Practice Address - Country:US
Practice Address - Phone:715-552-7303
Practice Address - Fax:715-552-7355
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-132113207RG0100X
IA04791207RG0100X
MIJP016277207RG0100X
WI44787-021207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1055201131OtherBLUE CROSS BLUE SHIELD
MI4693501Medicaid
MIP00165661OtherRAILROAD MEDICARE
WI43546500Medicaid
MIP00165661OtherRAILROAD MEDICARE
MI1055201131OtherBLUE CROSS BLUE SHIELD
MI4693501Medicaid