Provider Demographics
NPI:1730387374
Name:POTTER, RACHEL AMELIA (OD)
Entity type:Individual
Prefix:MISS
First Name:RACHEL
Middle Name:AMELIA
Last Name:POTTER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2829 PRINCE CIR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:CO
Mailing Address - Zip Code:80516-7536
Mailing Address - Country:US
Mailing Address - Phone:303-945-6828
Mailing Address - Fax:
Practice Address - Street 1:2080 MAIN ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-1916
Practice Address - Country:US
Practice Address - Phone:303-651-2020
Practice Address - Fax:303-776-2460
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT-2591152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO85605590Medicaid
810529Medicare PIN
CO4506580001Medicare NSC