MEDICARE: DR. SCOTT ELLIS POTTER I 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	MO-T-2750	MO

General Provider Information

NPI Number	:	1942394937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SCOTT ELLIS POTTER I O.D.

Provider Business Mailing Address
First Line	:	3509 NW 85TH ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64154-1157
Country	:	US
Telephone Number	:	816-436-4786
Fax Number	:

Provider Business Practice Location Address
First Line	:	19 NW BARRY RD
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64155-2728
Country	:	US
Telephone Number	:	816-468-4680
Fax Number	:	816-468-6444

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	07/08/2007

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