Provider Demographics
NPI:1508870742
Name:POTTER, AUSTIN DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:AUSTIN
Middle Name:DAVID
Last Name:POTTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3632 S CEDAR CREEK LN
Mailing Address - Street 2:
Mailing Address - City:NEW PALESTINE
Mailing Address - State:IN
Mailing Address - Zip Code:46163-8719
Mailing Address - Country:US
Mailing Address - Phone:317-753-8852
Mailing Address - Fax:
Practice Address - Street 1:5953 W BROADWAY
Practice Address - Street 2:
Practice Address - City:MC CORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46055-9355
Practice Address - Country:US
Practice Address - Phone:317-747-9263
Practice Address - Fax:317-747-9271
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003358A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000502302OtherANTHEM
IN138830BMedicare PIN