Provider Demographics
NPI:1982693578
Name:POTTER, CHERYL ANN (M D)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:ANN
Last Name:POTTER
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8400
Mailing Address - Fax:
Practice Address - Street 1:3090 RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-5865
Practice Address - Country:US
Practice Address - Phone:972-475-9505
Practice Address - Fax:972-412-6737
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3998207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX046031301Medicaid
TX046031301Medicaid
TX046031301Medicaid
TXG27392Medicare UPIN