Provider Demographics
NPI:1295739050
Name:POTTER, DARYL K (DPM)
Entity type:Individual
Prefix:
First Name:DARYL
Middle Name:K
Last Name:POTTER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 ASHBOURNE DR
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-7393
Mailing Address - Country:US
Mailing Address - Phone:502-633-7649
Mailing Address - Fax:
Practice Address - Street 1:4612 OUTER LOOP
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3971
Practice Address - Country:US
Practice Address - Phone:502-968-2233
Practice Address - Fax:502-968-2283
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY000271213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1054674OtherPASSPORT - GROUP
KY27-00311OtherUHC
KYP00112387OtherUHC RAILROAD
KY0620460004OtherPALMETTO - JEFFERSON CO
KY1157245OtherPASSPORT DME
KY000000332487OtherANTHEM
KY2026979OtherCIGNA
KY5000492OtherPASSPORT - INDIVIDUAL
KY80903495Medicaid
KY0620460003OtherPALMETTO - HARDIN CO
KY7969602OtherAETNA
KY1214621OtherCHA
KY80000466Medicaid
KY80903735Medicaid
KY80903735Medicaid
KY2000305Medicare ID - Type UnspecifiedINDIVIDUAL - JEFFERSON CO
KY80000466Medicaid