1386795896 NPI number — DR. MARK POTTER D.C.

Table of content: DR. MARK POTTER D.C. (NPI 1386795896)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386795896 NPI number — DR. MARK POTTER D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POTTER
Provider First Name:
MARK
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
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:
1386795896
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
366 MASSACHUSETTS AVE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02474-6733
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-648-8500
Provider Business Mailing Address Fax Number:
781-648-7171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
366 MASSACHUSETTS AVE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02474-6733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-648-8500
Provider Business Practice Location Address Fax Number:
781-648-7171
Provider Enumeration Date:
01/13/2007

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: 111N00000X , with the licence number:  921 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0781742 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: Y39404 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 4404373 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: Y35709 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 37821 . This is a "CIGNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 275461 . This is a "HEALTH SOURCE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 715211 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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