Provider Demographics
NPI:1326105669
Name:POTTER, GREG LELAND (DO)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:LELAND
Last Name:POTTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 WESLEY RD
Mailing Address - Street 2:
Mailing Address - City:DALEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24083-3082
Mailing Address - Country:US
Mailing Address - Phone:540-591-9440
Mailing Address - Fax:540-966-2719
Practice Address - Street 1:46 WESLEY RD
Practice Address - Street 2:
Practice Address - City:DALEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24083-3082
Practice Address - Country:US
Practice Address - Phone:540-591-9440
Practice Address - Fax:540-966-2719
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201361207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1326105669Medicaid
003019C51Medicare PIN
VA1326105669Medicaid
P00095325Medicare PIN