Healthcare Provider Details

I. General information

NPI: 1003920877
Provider Name (Legal Business Name): KIRK DAVID POTTER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3012 BROADWAY AVE
HAYS KS
67601-1916
US

IV. Provider business mailing address

3012 BROADWAY AVE
HAYS KS
67601-1916
US

V. Phone/Fax

Practice location:
  • Phone: 785-301-2250
  • Fax: 785-301-2270
Mailing address:
  • Phone: 785-301-2250
  • Fax: 785-301-2270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number05-33528
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number05-33528
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number05-33528
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number05-33528
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: