Provider Demographics
NPI:1861562217
Name:POTAZNICK, WALTER (OD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:
Last Name:POTAZNICK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:584 A HIGH STREET
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-1807
Mailing Address - Country:US
Mailing Address - Phone:781-471-4339
Mailing Address - Fax:781-471-4339
Practice Address - Street 1:584A HIGH ST
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-1807
Practice Address - Country:US
Practice Address - Phone:781-471-4338
Practice Address - Fax:781-471-4339
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA 2567T152WP0200X, 152WV0400X, 152WS0006X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA15655801Medicare PIN
MA156558Medicare PIN
MAU30841Medicare UPIN