Provider Demographics
NPI:1770643538
Name:POTTER, EDWARD VANCE (DC)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:VANCE
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 1:3424 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34235-8906
Mailing Address - Country:US
Mailing Address - Phone:941-955-7788
Mailing Address - Fax:941-365-8611
Practice Address - Street 1:3424 17TH ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34235-8906
Practice Address - Country:US
Practice Address - Phone:941-955-7788
Practice Address - Fax:941-365-8611
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4047111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT56005Medicare UPIN
FL88871Medicare ID - Type Unspecified