Provider Demographics
NPI:1578993077
Name:DOUGLAS H POTTER MD
Entity Type:Organization
Organization Name:DOUGLAS H POTTER MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:H
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-467-7020
Mailing Address - Street 1:1742 E RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14622-2157
Mailing Address - Country:US
Mailing Address - Phone:585-467-7020
Mailing Address - Fax:585-266-1612
Practice Address - Street 1:1742 E RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14622-2157
Practice Address - Country:US
Practice Address - Phone:585-467-7020
Practice Address - Fax:585-266-1612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-19
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003692-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty