Provider Demographics
NPI:1184635195
Name:POTOZKIN, JEROME (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:POTOZKIN
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 1:600 SAN RAMON VALLEY BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-4014
Mailing Address - Country:US
Mailing Address - Phone:925-838-4900
Mailing Address - Fax:925-838-4920
Practice Address - Street 1:600 SAN RAMON VALLEY BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-4014
Practice Address - Country:US
Practice Address - Phone:925-838-4900
Practice Address - Fax:925-838-4920
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73505207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G735050Medicare ID - Type Unspecified
CAF53323Medicare UPIN