Provider Demographics
NPI:1568514396
Name:POTTER, DOUGLAS S (CPO)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:S
Last Name:POTTER
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2526 E GUNNISON PL
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-5930
Mailing Address - Country:US
Mailing Address - Phone:208-765-8561
Mailing Address - Fax:
Practice Address - Street 1:2526 E GUNNISON PL
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-5930
Practice Address - Country:US
Practice Address - Phone:208-765-8561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist