Provider Demographics
NPI:1598752503
Name:POTTS, KENT H
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:H
Last Name:POTTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12905 DEERFIELD CT
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-5138
Mailing Address - Country:US
Mailing Address - Phone:405-752-0957
Mailing Address - Fax:
Practice Address - Street 1:2307 GORDON COOPER DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-9007
Practice Address - Country:US
Practice Address - Phone:405-878-4693
Practice Address - Fax:405-878-4690
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8526207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK060051779OtherRAILROAD MEDICARE
OK100104450AMedicaid
OK100104450AMedicaid
OKC95372Medicare UPIN