Provider Demographics
NPI:1356451637
Name:POTTER, TONY JOSEPH (DC)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:JOSEPH
Last Name:POTTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9632 EMERALD OAK DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-2258
Mailing Address - Country:US
Mailing Address - Phone:916-685-1234
Mailing Address - Fax:916-685-6214
Practice Address - Street 1:9632 EMERALD OAK DR
Practice Address - Street 2:SUITE B
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-2258
Practice Address - Country:US
Practice Address - Phone:916-685-1234
Practice Address - Fax:916-685-6214
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21781111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA440398Medicare UPIN
CADC0217810Medicare ID - Type Unspecified