MEDICARE: MARK S POTENZA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0122X	Plastic and Reconstructive Surgery Physician	167600	NY

General Provider Information

NPI Number	:	1134122096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK S POTENZA MD

Provider Business Mailing Address
First Line	:	PO BOX 2003
Second Line	:
City	:	EAST SYRACUSE
State	:	NY
Zip	:	13057-4503
Country	:	US
Telephone Number	:	315-449-3904
Fax Number	:	315-445-2936

Provider Business Practice Location Address
First Line	:	5700 W GENESEE ST
Second Line	:	STE 132
City	:	CAMILLUS
State	:	NY
Zip	:	13031-3212
Country	:	US
Telephone Number	:	315-487-5858
Fax Number	:	315-487-1950

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	12/20/2012

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Directions to “ MARK S POTENZA MD” Practice Location

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