Provider Demographics
NPI:1477520096
Name:POTTORFF, GREGG THOMAS (MD)
Entity type:Individual
Prefix:
First Name:GREGG
Middle Name:THOMAS
Last Name:POTTORFF
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 1:19842 LAKE CHABOT RD
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-4002
Mailing Address - Country:US
Mailing Address - Phone:510-886-8844
Mailing Address - Fax:510-247-8280
Practice Address - Street 1:19842 LAKE CHABOT RD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-4002
Practice Address - Country:US
Practice Address - Phone:510-886-8844
Practice Address - Fax:510-247-8280
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61064207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
F15734Medicare UPIN
00G610640Medicare ID - Type Unspecified