MEDICARE: JEROME R POTOZKIN MD, A PROFESSIONAL CORPORATION

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	207N00000X	Dermatology Physician	G73505	CA

General Provider Information

NPI Number	:	1093844292
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEROME R POTOZKIN MD, A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	600 SAN RAMON VALLEY BLVD
Second Line	:	SUITE 102
City	:	DANVILLE
State	:	CA
Zip	:	94526-4014
Country	:	US
Telephone Number	:	925-385-8980
Fax Number	:	925-838-4920

Provider Business Practice Location Address
First Line	:	600 SAN RAMON VALLEY BLVD
Second Line	:	SUITE 102
City	:	DANVILLE
State	:	CA
Zip	:	94526-4014
Country	:	US
Telephone Number	:	925-385-8980
Fax Number	:	925-838-4920

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JEROME POTOZKIN
Credential	:	M.D.
Telephone Number	:	925-838-4900

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	09/09/2011

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