Provider Demographics
NPI:1144314659
Name:POTTER, JOHN ROGER (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ROGER
Last Name:POTTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 13TH ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101
Mailing Address - Country:US
Mailing Address - Phone:606-329-0204
Mailing Address - Fax:606-324-7770
Practice Address - Street 1:700 13TH ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101
Practice Address - Country:US
Practice Address - Phone:606-329-0204
Practice Address - Fax:606-324-7770
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17883208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0406617Medicaid
KY336109752062212OtherBC SUPER BLUE PLUS
KY65917544Medicaid
KY22000000063411OtherANTHEM BC/BS
WV0110220000Medicaid
KY64178833Medicaid
KY610975206003OtherMT ST BC/BS
KY6109752062212OtherBC PPO
KY000000062599OtherANTHEM BC PROVIDER
KY12-029969OtherUNITED HEALTH CARE