Provider Demographics
NPI:1447226477
Name:POTTS, JERRY LYNN (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:LYNN
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 1:1408 W 43RD AVE
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-7010
Mailing Address - Country:US
Mailing Address - Phone:870-535-5719
Mailing Address - Fax:870-536-1963
Practice Address - Street 1:1408 W 43RD AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-7010
Practice Address - Country:US
Practice Address - Phone:870-535-5719
Practice Address - Fax:870-536-1963
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4520207K00000X, 207KA0200X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR54134OtherARKANSAS BLUE CROSS BLUE SHIELD
AR104787001Medicaid
AR541346924Medicare PIN
AR54134Medicare PIN