Provider Demographics
NPI:1881829547
Name:POTTHOFF, BRYAN (MD)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:
Last Name:POTTHOFF
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 1:14101 N. EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013
Mailing Address - Country:US
Mailing Address - Phone:405-340-1621
Mailing Address - Fax:405-340-1607
Practice Address - Street 1:14101 N. EASTERN AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013
Practice Address - Country:US
Practice Address - Phone:405-340-1621
Practice Address - Fax:405-340-1607
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-26
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27179207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine