Healthcare Provider Details

I. General information

NPI: 1245230143
Provider Name (Legal Business Name): MICHAEL W POTTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 08/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DEAN DR
CENTRAL POINT OR
97502-9706
US

IV. Provider business mailing address

100 DEAN DR
CENTRAL POINT OR
97502-9706
US

V. Phone/Fax

Practice location:
  • Phone: 541-944-1490
  • Fax: 541-664-8291
Mailing address:
  • Phone: 541-944-1490
  • Fax: 541-664-8291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number5552
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number10071
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberMD19851
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: