Provider Demographics
NPI:1639472632
Name:POTTER, DAVID EDMUND (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:EDMUND
Last Name:POTTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4757 WILLOW BEND DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310-1023
Mailing Address - Country:US
Mailing Address - Phone:940-696-8139
Mailing Address - Fax:
Practice Address - Street 1:2101 FM 369 N
Practice Address - Street 2:
Practice Address - City:IOWA PARK
Practice Address - State:TX
Practice Address - Zip Code:76367-6568
Practice Address - Country:US
Practice Address - Phone:940-855-7477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8347207Q00000X, 302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine