Provider Demographics
NPI:1831355064
Name:POTTER, KIM (MD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:THI
Other - Last Name:DO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6210 MALLOCH DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-6327
Mailing Address - Country:US
Mailing Address - Phone:901-736-2387
Mailing Address - Fax:
Practice Address - Street 1:1980 NONCONNAH BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38132-2123
Practice Address - Country:US
Practice Address - Phone:901-291-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-07
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN46257207P00000X
TNMD0000046257207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1518265Medicaid
TN1518265Medicaid