Healthcare Provider Details

I. General information

NPI: 1548209810
Provider Name (Legal Business Name): STAN E POTOCKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 06/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3621 22ND ST STE 300
LUBBOCK TX
79410-1301
US

IV. Provider business mailing address

3621 22ND ST STE 300
LUBBOCK TX
79410-1301
US

V. Phone/Fax

Practice location:
  • Phone: 806-792-5331
  • Fax: 806-792-9417
Mailing address:
  • Phone: 806-792-5331
  • Fax: 806-792-9417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberJ8719
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: