Provider Demographics
NPI:1497086177
Name:POTTER, GREGORY
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:POTTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 HILAND SPRINGS WAY
Mailing Address - Street 2:APT C
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-3115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:NAVAL HOSPITAL BMC MCAS
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542
Practice Address - Country:US
Practice Address - Phone:910-449-6500
Practice Address - Fax:910-449-6532
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman