Provider Demographics
NPI:1396839890
Name:POTTER, CHARLES R (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:POTTER
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:PO BOX 636930
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6930
Mailing Address - Country:US
Mailing Address - Phone:513-981-5123
Mailing Address - Fax:513-981-5015
Practice Address - Street 1:770 W HIGH ST
Practice Address - Street 2:SUITE 460
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-3990
Practice Address - Country:US
Practice Address - Phone:419-226-4300
Practice Address - Fax:419-226-4305
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6288207YX0905X
OH35.127414207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C39944Medicare UPIN