Provider Demographics
NPI:1942208590
Name:POTTER, IRA BLAINE (MD)
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:BLAINE
Last Name:POTTER
Suffix:
Gender:M
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:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:LACKEY
Mailing Address - State:KY
Mailing Address - Zip Code:41643-0190
Mailing Address - Country:US
Mailing Address - Phone:606-358-2381
Mailing Address - Fax:606-358-2404
Practice Address - Street 1:77 MILLARD ALLEN DR
Practice Address - Street 2:
Practice Address - City:LACKEY
Practice Address - State:KY
Practice Address - Zip Code:41643-0190
Practice Address - Country:US
Practice Address - Phone:606-358-2381
Practice Address - Fax:606-358-2404
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15918207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2139OtherCHA
KY000000045528OtherBCBS
KY64159189Medicaid
KY64159189Medicaid
C67900Medicare UPIN