Provider Demographics
NPI:1770746299
Name:POTT, EMILY MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:EMILY
Middle Name:MARIE
Last Name:POTT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:MARIE
Other - Last Name:SOUTHCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4160 IL ROUTE 83
Mailing Address - Street 2:SUITE 107
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047-8034
Mailing Address - Country:US
Mailing Address - Phone:847-955-9393
Mailing Address - Fax:847-955-9857
Practice Address - Street 1:4160 IL ROUTE 83
Practice Address - Street 2:SUITE 107
Practice Address - City:LONG GROVE
Practice Address - State:IL
Practice Address - Zip Code:60047-8034
Practice Address - Country:US
Practice Address - Phone:847-955-9393
Practice Address - Fax:847-955-9857
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010080152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL8825444OtherMULTIPLAN
IL1636706OtherBCBS
IL7235044OtherAETNA
ILK52611Medicare PIN
IL210209Medicare PIN
IL211019Medicare PIN