Provider Demographics
NPI:1740335090
Name:POTKIN, BENJAMIN N (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:N
Last Name:POTKIN
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 1:1595 SOQUEL DR
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-1719
Mailing Address - Country:US
Mailing Address - Phone:831-761-1680
Mailing Address - Fax:
Practice Address - Street 1:1595 SOQUEL DR
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1719
Practice Address - Country:US
Practice Address - Phone:831-761-1680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55040207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1720100480OtherGROUP NPI
CA1720100480OtherGROUP NPI