Provider Demographics
NPI:1265412605
Name:POTTER, DARRELL JACK (MD)
Entity type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:JACK
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 1:6214 SWEET CLOVER LN SE
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-8291
Mailing Address - Country:US
Mailing Address - Phone:334-322-3489
Mailing Address - Fax:
Practice Address - Street 1:5491 W ROSEBUD CT SE
Practice Address - Street 2:#4
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49512-9464
Practice Address - Country:US
Practice Address - Phone:334-322-3489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2019-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-01651207X00000X
IAMD-42830207X00000X
MO2016005465207X00000X
MI4301030727207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51041005OtherBCBS
AL41005Medicaid
AL51041005OtherBCBS