Provider Demographics
NPI:1801937263
Name:POTTER, VERNON DEWAINE (M D)
Entity type:Individual
Prefix:DR
First Name:VERNON
Middle Name:DEWAINE
Last Name:POTTER
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9829 S 1300 E
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-4000
Mailing Address - Country:US
Mailing Address - Phone:801-576-8988
Mailing Address - Fax:801-576-9396
Practice Address - Street 1:9829 S 1300 E
Practice Address - Street 2:SUITE 302
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-4000
Practice Address - Country:US
Practice Address - Phone:801-576-8988
Practice Address - Fax:801-576-9396
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT2939081205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT$$$$$$$$$016Medicaid
000012008Medicare PIN
UT$$$$$$$$$016Medicaid
000012008Medicare ID - Type Unspecified