Provider Demographics
NPI:1114083409
Name:POTTER, BRUCE J (OD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:J
Last Name:POTTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 E KING AVE
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93274-4223
Mailing Address - Country:US
Mailing Address - Phone:559-686-8628
Mailing Address - Fax:559-686-2507
Practice Address - Street 1:440 E KING AVE
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274-4223
Practice Address - Country:US
Practice Address - Phone:559-686-8628
Practice Address - Fax:559-686-2507
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 4601 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1801077953OtherMEDICARE NPI GROUP
CA94-1670985OtherVISION SERVICE PLAN
CA0678700001OtherMEDICARE D DMERC (NAS)
CAYYY41591YMedicaid
CAYYY41591YMedicare ID - Type Unspecified
CAT09712Medicare UPIN
CAYYY41591YMedicaid