Provider Demographics
NPI:1467454496
Name:POTTER, J. ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:J.
Middle Name:ALLEN
Last Name:POTTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 EASTGATE DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-9271
Mailing Address - Country:US
Mailing Address - Phone:309-698-2020
Mailing Address - Fax:309-698-0368
Practice Address - Street 1:93 EASTGATE DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-9271
Practice Address - Country:US
Practice Address - Phone:309-698-2020
Practice Address - Fax:309-698-0368
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-006242152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL264900Medicare ID - Type Unspecified
ILU11293Medicare UPIN
IL0203770001Medicare NSC