Provider Demographics
NPI:1841216496
Name:J T POTTER JR MD PC
Entity type:Organization
Organization Name:J T POTTER JR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-679-0800
Mailing Address - Street 1:159 RIDGEFIELD RD SW
Mailing Address - Street 2:
Mailing Address - City:WISE
Mailing Address - State:VA
Mailing Address - Zip Code:24293-5607
Mailing Address - Country:US
Mailing Address - Phone:276-679-0800
Mailing Address - Fax:276-679-0097
Practice Address - Street 1:611 TRENT ST NE
Practice Address - Street 2:SUITE A
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273
Practice Address - Country:US
Practice Address - Phone:276-679-0800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012324682080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010002761Medicaid
VAH91349Medicare UPIN