=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457582983
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHERINE MARIE POTTER O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2009
-----------------------------------------------------
Last Update Date | 10/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3600 ONEIL DR
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49202-1857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-788-6104
-----------------------------------------------------
Fax | 517-788-6106
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1122 ARMS ST APARTMENT 14
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49068-2123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-980-0837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4901004526
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------