Provider Demographics
NPI:1710190046
Name:POTOCZAK, DOUGLAS J (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:POTOCZAK
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:PO BOX 636643
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6643
Mailing Address - Country:US
Mailing Address - Phone:440-989-3801
Mailing Address - Fax:440-690-0264
Practice Address - Street 1:6115 EMERALD ST
Practice Address - Street 2:
Practice Address - City:N RIDGEVILLE
Practice Address - State:OH
Practice Address - Zip Code:44039-2047
Practice Address - Country:US
Practice Address - Phone:440-406-5800
Practice Address - Fax:216-201-6914
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35060432207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3025372Medicaid
OH0897874Medicaid
OH0897874Medicaid
OHF43886Medicare UPIN
OH9389631Medicare PIN