1114083409 NPI number — DR. BRUCE J POTTER O.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114083409 NPI number — DR. BRUCE J POTTER O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POTTER
Provider First Name:
BRUCE
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114083409
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
440 E KING AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TULARE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93274-4223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-686-8628
Provider Business Mailing Address Fax Number:
559-686-2507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
440 E KING AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TULARE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93274-4223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-686-8628
Provider Business Practice Location Address Fax Number:
559-686-2507
Provider Enumeration Date:
12/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT 4601 TPA , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1801077953 . This is a "MEDICARE NPI GROUP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 94-1670985 . This is a "VISION SERVICE PLAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 0678700001 . This is a "MEDICARE D DMERC (NAS)" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: YYY41591Y , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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