Provider Demographics
NPI:1851566475
Name:POTTS, KELLEY SMITH (MD)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:SMITH
Last Name:POTTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CHARTER LN
Mailing Address - Street 2:APT. 409
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-4534
Mailing Address - Country:US
Mailing Address - Phone:478-319-7834
Mailing Address - Fax:
Practice Address - Street 1:UT COLLEGE OF MEDICINE 920 MADISON AVE
Practice Address - Street 2:SUITE C50
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38163-0001
Practice Address - Country:US
Practice Address - Phone:901-448-5364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA747592085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program