Provider Demographics
NPI:1134122096
Name:POTENZA, MARK S (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:POTENZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2003
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-4503
Mailing Address - Country:US
Mailing Address - Phone:315-449-3904
Mailing Address - Fax:315-445-2936
Practice Address - Street 1:5700 W GENESEE ST
Practice Address - Street 2:STE 132
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-3212
Practice Address - Country:US
Practice Address - Phone:315-487-5858
Practice Address - Fax:315-487-1950
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1676002086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
F31752Medicare UPIN