Provider Demographics
NPI:1386671576
Name:POTTS, JEROME F (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:F
Last Name:POTTS
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 1:2810 NICOLLET AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-4708
Mailing Address - Country:US
Mailing Address - Phone:612-873-8080
Mailing Address - Fax:612-545-9259
Practice Address - Street 1:2810 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-4708
Practice Address - Country:US
Practice Address - Phone:612-873-8080
Practice Address - Fax:612-545-9259
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26666207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN781787800Medicaid
MN080000843Medicare ID - Type Unspecified
MN781787800Medicaid