Provider Demographics
NPI:1700842747
Name:POTTER, DAVID M (DC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:POTTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 RUTH ROAD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:NORTH BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08902
Mailing Address - Country:US
Mailing Address - Phone:732-398-1600
Mailing Address - Fax:732-398-1616
Practice Address - Street 1:1555 RUTH ROAD
Practice Address - Street 2:SUITE 3
Practice Address - City:NORTH BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08902
Practice Address - Country:US
Practice Address - Phone:732-398-1600
Practice Address - Fax:732-398-1616
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00482100111N00000X
AZ5519111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU61286Medicare UPIN
NJ852944Medicare PIN