Healthcare Provider Details

I. General information

NPI: 1689640955
Provider Name (Legal Business Name): MARK K. POTTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 POPE ST SUITE 106
SAINT HELENA CA
94574-1280
US

IV. Provider business mailing address

1127 POPE ST SUITE 106
SAINT HELENA CA
94574-1280
US

V. Phone/Fax

Practice location:
  • Phone: 707-967-1970
  • Fax: 707-967-1972
Mailing address:
  • Phone: 707-967-1970
  • Fax: 707-967-1972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG86920
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: