Provider Demographics
NPI:1255868451
Name:POTILECHIO, MEGAN DANIELLE (DO)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:DANIELLE
Last Name:POTILECHIO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 E GRANT RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2805
Mailing Address - Country:US
Mailing Address - Phone:520-324-2308
Mailing Address - Fax:520-324-1406
Practice Address - Street 1:5301 E GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2805
Practice Address - Country:US
Practice Address - Phone:520-324-2308
Practice Address - Fax:520-324-1406
Is Sole Proprietor?:No
Enumeration Date:2017-05-18
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR3459207RH0002X
MI5151011188390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program