Provider Demographics
NPI:1619998317
Name:POTOCKI, JASON J (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:J
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 1:1000 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5703
Mailing Address - Country:US
Mailing Address - Phone:715-387-5511
Mailing Address - Fax:
Practice Address - Street 1:3501 CRANBERRY BLVD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-5213
Practice Address - Country:US
Practice Address - Phone:715-393-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60046207X00000X, 207XS0117X
GA064444207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01062299AOtherPHYSICIAN LICENSE
GA064444OtherLICENSE
IN01062299BOtherCSR
KY40457OtherPHYSICIAN LICENSE
IN200828920OtherIHCP
NC200700867OtherLICENSE
KY000000485767OtherANTHEM