Provider Demographics
NPI:1124194345
Name:POTVIN, JEAN DEREK (DC)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:DEREK
Last Name:POTVIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24470 DEL PRADO
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-2739
Mailing Address - Country:US
Mailing Address - Phone:949-488-0348
Mailing Address - Fax:
Practice Address - Street 1:24470 DEL PRADO
Practice Address - Street 2:
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-2739
Practice Address - Country:US
Practice Address - Phone:949-488-0348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC-27513111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA487877Medicare UPIN