Healthcare Provider Details

I. General information

NPI: 1184184277
Provider Name (Legal Business Name): SHELBY MARIE POTKIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2019
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 ANNE ST NW
BEMIDJI MN
56601-5114
US

IV. Provider business mailing address

2456 248TH ST
LOMITA CA
90717-1515
US

V. Phone/Fax

Practice location:
  • Phone: 218-333-2020
  • Fax:
Mailing address:
  • Phone: 831-332-7168
  • Fax: 562-206-2507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA206239
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number74023
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: