Healthcare Provider Details

I. General information

NPI: 1619051497
Provider Name (Legal Business Name): TROY L POTTHOFF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 2ND AVE UNIT 1803
SEATTLE WA
98121-4020
US

IV. Provider business mailing address

2015 2ND AVE UNIT 1803
SEATTLE WA
98121-4020
US

V. Phone/Fax

Practice location:
  • Phone: 308-455-6788
  • Fax:
Mailing address:
  • Phone: 308-455-6788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR0057906
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number19526
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19526
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: