Provider Demographics
NPI:1346438603
Name:POTTER, ELISABETH H (MD)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:H
Last Name:POTTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 W 34TH ST
Mailing Address - Street 2:SUITE 321
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1907
Mailing Address - Country:US
Mailing Address - Phone:512-867-6211
Mailing Address - Fax:512-561-0858
Practice Address - Street 1:6818 AUSTIN CENTER BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3158
Practice Address - Country:US
Practice Address - Phone:512-867-6211
Practice Address - Fax:512-561-0858
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP73312086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX327193402Medicaid
TX327193401Medicaid
TX327193401Medicaid