Provider Demographics
NPI:1467404210
Name:POTTER, RACHAEL SUZANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:RACHAEL
Middle Name:SUZANNE
Last Name:POTTER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2408 VIOLA HEIGHTS DR NE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906-6941
Mailing Address - Country:US
Mailing Address - Phone:507-289-6513
Mailing Address - Fax:
Practice Address - Street 1:1820 E MADISON AVE
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5448
Practice Address - Country:US
Practice Address - Phone:507-387-6517
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2785152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU82514Medicare UPIN