Provider Demographics
NPI:1811994718
Name:POTSCHKA, GRETCHEN MARIE (MD)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:MARIE
Last Name:POTSCHKA
Suffix:
Gender:F
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:PO BOX 3002
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-0302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2310
Practice Address - Country:US
Practice Address - Phone:360-414-2385
Practice Address - Fax:360-414-2386
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042178207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00019811OtherRR MEDICARE
WA171088OtherLABOR & IND.
WA8359192Medicaid
OR226976Medicaid
WA8932202OtherCRIME VICTIMS
OR226976Medicaid
WA171088OtherLABOR & IND.