Provider Demographics
NPI:1730189077
Name:POTTER, MICHEAL (MD)
Entity type:Individual
Prefix:
First Name:MICHEAL
Middle Name:
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 1:860 OMNI BLVD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4430
Mailing Address - Country:US
Mailing Address - Phone:757-232-8777
Mailing Address - Fax:757-232-8866
Practice Address - Street 1:860 OMNI BLVD
Practice Address - Street 2:STE 113
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4434
Practice Address - Country:US
Practice Address - Phone:757-327-0657
Practice Address - Fax:757-240-5096
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101056088207Q00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA191819OtherANTHEM
VA5627541Medicaid
VA189518OtherANTHEM
080177662OtherRR/MEDICARE
080177662OtherRR/MEDICARE
VA189518OtherANTHEM