Provider Demographics
NPI:1700861465
Name:POTTER, JEFFREY N (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:N
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-579-5400
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:805 HALL ST
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-2110
Practice Address - Country:US
Practice Address - Phone:601-928-4412
Practice Address - Fax:601-579-5240
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23577207Q00000X
PAMD024152E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
50000729OtherCAP BLUE CROSS
MS05706756Medicaid
PA0008570430005Medicaid
151890OtherHIGHMARK BLUE SHIELD
50000729OtherCAP BLUE CROSS
MS386181YKFFMedicare PIN
PA151890Medicare PIN