MEDICARE: MARIOS POTAMITIS IDC

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	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1679931299
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIOS POTAMITIS IDC

Provider Business Mailing Address
First Line	:	1295 STATION VILLAGE WAY
Second Line	:	APARTMENT #1406
City	:	SAN DIEGO
State	:	CA
Zip	:	92108
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2195 STATION VILLAGE WAY
Second Line	:	APARTMENT #1406
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-6514
Country	:	US
Telephone Number	:	760-908-8094
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/10/2016
Last Update Date	:	02/10/2016

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Directions to “ MARIOS POTAMITIS IDC” Practice Location

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