Provider Demographics
NPI:1760593255
Name:POTTER, MARK E (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:POTTER
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 1:22950 SCHRAM RD
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:NE
Mailing Address - Zip Code:68028-4888
Mailing Address - Country:US
Mailing Address - Phone:402-980-6752
Mailing Address - Fax:
Practice Address - Street 1:22950 SCHRAM RD
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:NE
Practice Address - Zip Code:68028-4888
Practice Address - Country:US
Practice Address - Phone:402-980-6752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE21670207V00000X, 207VX0201X
IA34300207V00000X, 207VX0201X
NE6190183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
99255OtherWELLMARK-CENTER
C74960Medicare UPIN
IAI10490Medicare ID - Type Unspecified
NE10025407200Medicaid
99235OtherWELLMARK-S. 24TH
99234OtherWELLMARK-LAKESIDE
06281OtherWELLMARK-ATLANTIC
NE42150546518Medicaid
NE42150546516Medicaid
NE42150546517Medicaid
01617OtherBCBSN
IA6538702Medicaid
NE277121Medicare ID - Type Unspecified
IA1538702Medicaid