Provider Demographics
NPI:1598101685
Name:POTT, THOMAS ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ROBERT
Last Name:POTT
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 1:945 OTTAWA AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1431
Mailing Address - Country:US
Mailing Address - Phone:616-732-6204
Mailing Address - Fax:
Practice Address - Street 1:945 OTTAWA AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1431
Practice Address - Country:US
Practice Address - Phone:616-732-6204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-15
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301102809208000000X, 2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics