Provider Demographics
NPI:1245218767
Name:POTTER, DALE A (OD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:A
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 1:2349 DANVILLE RD SW
Mailing Address - Street 2:SUITE 410
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35603-4284
Mailing Address - Country:US
Mailing Address - Phone:256-353-2392
Mailing Address - Fax:256-353-8489
Practice Address - Street 1:2349 DANVILLE RD SW
Practice Address - Street 2:SUITE 410
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35603-4284
Practice Address - Country:US
Practice Address - Phone:256-353-2392
Practice Address - Fax:256-353-8489
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS456TA074152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000058307Medicaid
AL051044598OtherBLUECROSSBLUESHIELD
AL051044598OtherBLUECROSSBLUESHIELD
AL000058307Medicaid
AL0207410001Medicare NSC
MP0761331OtherDEA NUMBER