Provider Demographics
NPI:1245290790
Name:POTTER, DAVID (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:POTTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:41 MONTEBELLO RD STE 116
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1366
Mailing Address - Country:US
Mailing Address - Phone:719-545-2746
Mailing Address - Fax:719-542-9638
Practice Address - Street 1:41 MONTEBELLO RD STE 116
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-1366
Practice Address - Country:US
Practice Address - Phone:719-545-2746
Practice Address - Fax:719-542-9638
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41306207L00000X, 207LA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTT1106Medicaid
CO44935528Medicaid
P00031286OtherRAILROAD MEDICARE
UTT1106Medicaid