Provider Demographics
NPI:1508036658
Name:ANTHONY J POTOCHICK OD PA
Entity Type:Organization
Organization Name:ANTHONY J POTOCHICK OD PA
Other - Org Name:5 POINTS EYE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:POTOCHICK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:907-387-4057
Mailing Address - Street 1:2036 FORBES ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-3802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:904-387-1026
Practice Address - Street 1:2036 FORBES ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-3802
Practice Address - Country:US
Practice Address - Phone:904-387-4057
Practice Address - Fax:904-387-1026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2902152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621350200Medicaid
FL6335890001Medicare NSC