MEDICARE: DR. ROXANNA THELMA POTTER O.D.

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	OPT.005738	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	:	1790797579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROXANNA THELMA POTTER O.D.

Provider Business Mailing Address
First Line	:	1950 OLD GALLOWS RD STE 520
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22182-3970
Country	:	US
Telephone Number	:
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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	03/09/2022

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