Healthcare Provider Details

I. General information

NPI: 1376536789
Provider Name (Legal Business Name): ROBERT ALEXANDER POTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 QUAKER LN SUITE 200 D
HIGH POINT NC
27262-3832
US

IV. Provider business mailing address

624 QUAKER LN SUITE 200 D
HIGH POINT NC
27262-3832
US

V. Phone/Fax

Practice location:
  • Phone: 336-878-6101
  • Fax: 336-878-6155
Mailing address:
  • Phone: 336-878-6101
  • Fax: 336-878-6155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD067652L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2006-01965
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier5906078
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 2
IdentifierNC1154
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer
# 3
Identifier0017550100007
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: