Provider Demographics
NPI:1407370091
Name:POTOMAK, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:POTOMAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7768 258TH ST
Mailing Address - Street 2:
Mailing Address - City:ALDERGROVE
Mailing Address - State:BC
Mailing Address - Zip Code:V4W1V4
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2520 JAMES ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-3545
Practice Address - Country:US
Practice Address - Phone:360-393-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-26
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60763417152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist