Healthcare Provider Details

I. General information

NPI: 1124048442
Provider Name (Legal Business Name): ERIC GORDON POTWARDOWSKI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 12/01/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 N BROADWAY
ESCONDIDO CA
92025-1870
US

IV. Provider business mailing address

732 N BROADWAY
ESCONDIDO CA
92025-1870
US

V. Phone/Fax

Practice location:
  • Phone: 800-290-5000
  • Fax: 760-839-7037
Mailing address:
  • Phone: 800-290-5000
  • Fax: 760-839-7037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A9576
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: