Provider Demographics
NPI:1063568152
Name:POTVIN, ELIZABETH A (OD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:POTVIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:LECLAIRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2450 NE MARY ROSE PL
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7132
Mailing Address - Country:US
Mailing Address - Phone:541-318-8388
Mailing Address - Fax:
Practice Address - Street 1:2450 NE MARY ROSE PL
Practice Address - Street 2:SUITE 110
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7132
Practice Address - Country:US
Practice Address - Phone:541-318-8388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004355152W00000X
ORAT3479152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI944923648Medicaid