Provider Demographics
NPI:1184304891
Name:POTTS, LOGAN (IDMT)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:POTTS
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2175 REILLY ST
Mailing Address - Street 2:
Mailing Address - City:FORT LIBERTY
Mailing Address - State:NC
Mailing Address - Zip Code:28310-8526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:553 THUNDERBOLT ROAD
Practice Address - Street 2:
Practice Address - City:POPE AAF
Practice Address - State:NC
Practice Address - Zip Code:28308
Practice Address - Country:US
Practice Address - Phone:740-403-9830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians