Provider Demographics
NPI:1851313266
Name:POTTER, JEFFERY S (DO)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:S
Last Name:POTTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-0280
Mailing Address - Country:US
Mailing Address - Phone:606-349-7474
Mailing Address - Fax:606-349-7737
Practice Address - Street 1:842 E MOUNTAIN PKWY
Practice Address - Street 2:
Practice Address - City:SALYERSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41465-8378
Practice Address - Country:US
Practice Address - Phone:606-349-8100
Practice Address - Fax:606-349-8150
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02805207P00000X, 2084A0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64061328Medicaid
KY000000360776OtherANTHEM
KYP00274419OtherRR-MEDICARE
WV3000160OtherBWC
WV3004971000Medicaid
KYH74710Medicare UPIN
KY64061328Medicaid