Provider Demographics
NPI:1972547180
Name:POTTER, CHAD JEREMY (MD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:JEREMY
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 1:1550 E REPUBLIC RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-6530
Mailing Address - Country:US
Mailing Address - Phone:417-889-6102
Mailing Address - Fax:417-889-6289
Practice Address - Street 1:3801 SOUTH NATIONAL
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807
Practice Address - Country:US
Practice Address - Phone:417-269-4056
Practice Address - Fax:417-269-5556
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20060152252085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1256OtherBLUE
AR150984001Medicaid
MO201291606Medicaid
MOP00419521OtherRRR MEDICARE
MO1256OtherBLUE
H95780Medicare UPIN