MEDICARE: POTTER OPTOMETRY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	5738/T2652	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003088626
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POTTER OPTOMETRY, INC.

Provider Business Mailing Address
First Line	:	8006 N BRIDGE WAY
Second Line	:
City	:	MAUMEE
State	:	OH
Zip	:	43537-9495
Country	:	US
Telephone Number	:	419-885-5300
Fax Number	:

Provider Business Practice Location Address
First Line	:	8254 MAYBERRY SQ N
Second Line	:
City	:	SYLVANIA
State	:	OH
Zip	:	43560-9457
Country	:	US
Telephone Number	:	419-885-5300
Fax Number	:	419-885-5308

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROXANNA T POTTER
Credential	:	O.D.
Telephone Number	:	419-705-5143

Provider Enumeration Date	:	03/25/2008
Last Update Date	:	12/27/2019

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Directions to “POTTER OPTOMETRY, INC. ” Practice Location

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