Provider Demographics
NPI:1710043096
Name:POTKIN, RALPH TERRY (MD)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:TERRY
Last Name:POTKIN
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 1:1125 S BEVERLY DR
Mailing Address - Street 2:#406
Mailing Address - City:LA
Mailing Address - State:CA
Mailing Address - Zip Code:90035
Mailing Address - Country:US
Mailing Address - Phone:310-551-1178
Mailing Address - Fax:310-551-2047
Practice Address - Street 1:1125 S BEVERLY DR
Practice Address - Street 2:#406
Practice Address - City:LA
Practice Address - State:CA
Practice Address - Zip Code:90035
Practice Address - Country:US
Practice Address - Phone:310-551-1178
Practice Address - Fax:310-551-2047
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38416207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G384160Medicaid
CAWG384160Medicare ID - Type Unspecified
CA00G384160Medicaid