Provider Demographics
NPI:1255803136
Name:POTTS, DERRON M
Entity type:Individual
Prefix:
First Name:DERRON
Middle Name:M
Last Name:POTTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3454 MONTICELLO BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44121-1530
Mailing Address - Country:US
Mailing Address - Phone:919-500-2553
Mailing Address - Fax:
Practice Address - Street 1:3454 MONTICELLO BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44121-1530
Practice Address - Country:US
Practice Address - Phone:919-500-2553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator