Provider Demographics
NPI:1790797579
Name:POTTER, ROXANNA THELMA (OD)
Entity Type:Individual
Prefix:DR
First Name:ROXANNA
Middle Name:THELMA
Last Name:POTTER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ROXANNA
Other - Middle Name:THELMA
Other - Last Name:WEISENBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8254 MAYBERRY SQ N
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-9457
Practice Address - Country:US
Practice Address - Phone:419-885-5300
Practice Address - Fax:419-885-5308
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.005738152W00000X
OH5738 / T2652152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2831467Medicaid
OH2831467Medicaid
OHPO0627165Medicare PIN