Healthcare Provider Details

I. General information

NPI: 1073666087
Provider Name (Legal Business Name): JACK BENSON POTTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 JOHNSON FERRY RD NE SUITE 410
ATLANTA GA
30342-1631
US

IV. Provider business mailing address

960 JOHNSON FERRY RD NE SUITE 410
ATLANTA GA
30342-1631
US

V. Phone/Fax

Practice location:
  • Phone: 404-256-3788
  • Fax: 404-847-9613
Mailing address:
  • Phone: 404-256-3788
  • Fax: 404-847-9613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number29755
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: