Healthcare Provider Details

I. General information

NPI: 1073808101
Provider Name (Legal Business Name): SCOTT EDWARD POTENTA MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2011
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 DAGGETT AVE
KLAMATH FALLS OR
97601-7101
US

IV. Provider business mailing address

2900 DAGGETT AVE
KLAMATH FALLS OR
97601-7101
US

V. Phone/Fax

Practice location:
  • Phone: 541-884-1317
  • Fax: 541-274-4395
Mailing address:
  • Phone: 541-205-3974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD190554
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2018-00043
License Number StateNC

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: