Provider Demographics
NPI:1720168545
Name:POTUCEK, DAVID J (MSPT, CFMT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:J
Last Name:POTUCEK
Suffix:
Gender:M
Credentials:MSPT, CFMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 GEORGETOWN RD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:CT
Mailing Address - Zip Code:06883-1234
Mailing Address - Country:US
Mailing Address - Phone:203-305-3503
Mailing Address - Fax:
Practice Address - Street 1:1300 POST RD STE 210
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6038
Practice Address - Country:US
Practice Address - Phone:203-557-9111
Practice Address - Fax:203-601-7110
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0007569225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist