Healthcare Provider Details

I. General information

NPI: 1467454496
Provider Name (Legal Business Name): J. ALLEN POTTER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 03/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93 EASTGATE DR
WASHINGTON IL
61571-9271
US

IV. Provider business mailing address

93 EASTGATE DR
WASHINGTON IL
61571-9271
US

V. Phone/Fax

Practice location:
  • Phone: 309-698-2020
  • Fax: 309-698-0368
Mailing address:
  • Phone: 309-698-2020
  • Fax: 309-698-0368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-006242
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: