Provider Demographics
NPI:1245230143
Name:POTTER, MICHAEL W (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:W
Last Name:POTTER
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 1:100 DEAN DR
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-9706
Mailing Address - Country:US
Mailing Address - Phone:541-944-1490
Mailing Address - Fax:541-664-8291
Practice Address - Street 1:100 DEAN DR
Practice Address - Street 2:
Practice Address - City:CENTRAL POINT
Practice Address - State:OR
Practice Address - Zip Code:97502-9706
Practice Address - Country:US
Practice Address - Phone:541-944-1490
Practice Address - Fax:541-664-8291
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5552207T00000X
ND10071207T00000X
ORMD19851207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXPY187234Medicaid
OR079835Medicaid
OR079835Medicaid
CAXPY187234Medicaid