Provider Demographics
NPI:1821208075
Name:POTEET, JASON R (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:POTEET
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:5001 S COOPER ST STE 201
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-5993
Mailing Address - Country:US
Mailing Address - Phone:866-367-8768
Mailing Address - Fax:817-541-9555
Practice Address - Street 1:7100 OAKMONT BLVD STE 101
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3908
Practice Address - Country:US
Practice Address - Phone:866-367-8768
Practice Address - Fax:817-541-9540
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
TXN9115208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA07939Medicaid