Provider Demographics
NPI:1801198510
Name:POTTER FAMILY EYE CARE, LLC
Entity Type:Organization
Organization Name:POTTER FAMILY EYE CARE, LLC
Other - Org Name:POTTER FAMILY EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:317-747-9263
Mailing Address - Street 1:5953 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MC CORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46055-9355
Mailing Address - Country:US
Mailing Address - Phone:317-747-9263
Mailing Address - Fax:317-747-9271
Practice Address - Street 1:5953 W BROADWAY
Practice Address - Street 2:
Practice Address - City:MC CORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46055-9355
Practice Address - Country:US
Practice Address - Phone:317-747-9263
Practice Address - Fax:317-747-9271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003358A152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN6592970001OtherMEDICARE DMEPOS PTAN
INM100047360OtherMEDICARE PTAN