Provider Demographics
NPI:1548209810
Name:POTOCKI, STAN E (MD)
Entity Type:Individual
Prefix:
First Name:STAN
Middle Name:E
Last Name:POTOCKI
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 1:3621 22ND ST
Mailing Address - Street 2:STE 300
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1301
Mailing Address - Country:US
Mailing Address - Phone:806-792-5331
Mailing Address - Fax:806-792-9417
Practice Address - Street 1:3621 22ND ST
Practice Address - Street 2:STE 300
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1301
Practice Address - Country:US
Practice Address - Phone:806-792-5331
Practice Address - Fax:806-792-9417
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8719207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX029832501Medicaid
TX040016967OtherRAILROAD MEDICARE
TX88681XOtherBC/BS
TX00223JMedicare PIN
TX8F3579Medicare PIN
TX029832501Medicaid