Provider Demographics
NPI:1407394109
Name:CLINTON J POTTER MD PA
Entity Type:Organization
Organization Name:CLINTON J POTTER MD PA
Other - Org Name:ADVANCED INDIVIDUALIZED MEDICINE OF NAPLES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:J
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-377-7905
Mailing Address - Street 1:3180 SEASONS WAY UNIT 901
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-2375
Mailing Address - Country:US
Mailing Address - Phone:415-377-7905
Mailing Address - Fax:
Practice Address - Street 1:720 GOODLETTE RD N
Practice Address - Street 2:STE. 204
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5656
Practice Address - Country:US
Practice Address - Phone:239-260-3880
Practice Address - Fax:239-260-3881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 103986261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care