Provider Demographics
NPI:1407922446
Name:POTTER, STEVEN JARED (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:JARED
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 1:480 RIGBY LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442
Mailing Address - Country:US
Mailing Address - Phone:801-230-5182
Mailing Address - Fax:208-745-3501
Practice Address - Street 1:480 RIGBY LAKE DRIVE
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442
Practice Address - Country:US
Practice Address - Phone:208-745-3500
Practice Address - Fax:208-745-3501
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT57481181205207Q00000X
IDM-19057207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT57481181205OtherLICENSE NUMBER