Healthcare Provider Details

I. General information

NPI: 1477520096
Provider Name (Legal Business Name): GREGG THOMAS POTTORFF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 06/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19842 LAKE CHABOT RD
CASTRO VALLEY CA
94546-4002
US

IV. Provider business mailing address

19842 LAKE CHABOT RD
CASTRO VALLEY CA
94546-4002
US

V. Phone/Fax

Practice location:
  • Phone: 510-886-8844
  • Fax: 510-247-8280
Mailing address:
  • Phone: 510-886-8844
  • Fax: 510-247-8280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberG61064
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberG61064
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: