Healthcare Provider Details

I. General information

NPI: 1063971240
Provider Name (Legal Business Name): MATTHEW EDWARDS POTTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 SANTA MARIA WAY
SANTA MARIA CA
93455-2118
US

IV. Provider business mailing address

2050 S BLOSSER RD
SANTA MARIA CA
93458-7310
US

V. Phone/Fax

Practice location:
  • Phone: 805-934-5400
  • Fax: 805-938-9207
Mailing address:
  • Phone: 805-361-8030
  • Fax: 805-361-8097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11839167-1204
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20003
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: