Provider Demographics
NPI:1184946790
Name:POTTS, NATASHA NACOLE (OD)
Entity type:Individual
Prefix:DR
First Name:NATASHA
Middle Name:NACOLE
Last Name:POTTS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5240 MADISON AVE
Mailing Address - Street 2:APT B-1
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-1171
Mailing Address - Country:US
Mailing Address - Phone:231-903-8992
Mailing Address - Fax:
Practice Address - Street 1:5110 TIMES SQUARE PL
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1161
Practice Address - Country:US
Practice Address - Phone:517-381-8314
Practice Address - Fax:517-381-8328
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004557152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist