Healthcare Provider Details

I. General information

NPI: 1588959878
Provider Name (Legal Business Name): MANDY M POTTER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2011
Last Update Date: 02/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4685 BELDING RD NE
ROCKFORD MI
49341
US

IV. Provider business mailing address

5900 BYRON CENTER AVE SW
WYOMING MI
49519-9606
US

V. Phone/Fax

Practice location:
  • Phone: 616-252-3100
  • Fax: 616-252-3120
Mailing address:
  • Phone: 616-252-3243
  • Fax: 616-252-0260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0102203220
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: