Provider Demographics
NPI:1457582983
Name:POTTER, KATHERINE MARIE (OD)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:MARIE
Last Name:POTTER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1122 ARMS ST
Mailing Address - Street 2:APARTMENT 14
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-2123
Mailing Address - Country:US
Mailing Address - Phone:517-980-0837
Mailing Address - Fax:
Practice Address - Street 1:3600 ONEIL DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-1857
Practice Address - Country:US
Practice Address - Phone:517-788-6104
Practice Address - Fax:517-788-6106
Is Sole Proprietor?:No
Enumeration Date:2009-07-31
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004526152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist