Provider Demographics
NPI:1518932698
Name:POTOKA, DOUGLAS A (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:A
Last Name:POTOKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 5TH AVE
Mailing Address - Street 2:CHILDREN'S HOSPITAL, 48485
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213-2524
Mailing Address - Country:US
Mailing Address - Phone:412-692-7280
Mailing Address - Fax:
Practice Address - Street 1:3705 5TH AVE
Practice Address - Street 2:CHILDREN'S HOSPITAL, 48485
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-2524
Practice Address - Country:US
Practice Address - Phone:412-692-7280
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD074039L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101318958Medicaid
PA091516FKYMedicare ID - Type Unspecified