Healthcare Provider Details

I. General information

NPI: 1023092897
Provider Name (Legal Business Name): CHARLES F POTTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 01/15/2024
Certification Date: 01/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 BAXTER ST
ATHENS GA
30606-3712
US

IV. Provider business mailing address

PO BOX 48089
ATHENS GA
30604-8089
US

V. Phone/Fax

Practice location:
  • Phone: 706-769-0005
  • Fax:
Mailing address:
  • Phone: 706-389-3740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number90099
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: