Provider Demographics
NPI:1730180423
Name:POTTER, ERIC C (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:C
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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2066
Mailing Address - Fax:423-857-2070
Practice Address - Street 1:2033 MEADOWVIEW LN
Practice Address - Street 2:STE 200
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-7569
Practice Address - Country:US
Practice Address - Phone:423-857-2793
Practice Address - Fax:423-578-8025
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36165207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00635228OtherRAILROAD MEDICARE
TN4178280OtherBCBST
TN38763541Medicaid
TN4142480Medicaid
KY7100046250OtherKENTUCKY MEDICAID
TN3876358Medicare PIN
TN38763541Medicaid
TNH64817Medicare UPIN